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Chiarello D, Perrone A, Ricci E, Ferrera G, Duranti F, Bonetti S, Marchiani V, Fetta A, Lanari M, Cordelli DM. The Role of Electroencephalography in Children with Acute Altered Mental Status of Unknown Etiology: A Prospective Study. Neuropediatrics 2024. [PMID: 39106957 DOI: 10.1055/a-2380-6743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Acute altered mental status (AAMS) is often a challenge for clinicians, since the underlying etiologies cannot always easily be inferred based on the patient's clinical presentation, medical history, or early examinations. The aim of this study is to evaluate the role of electroencephalogram (EEG) as a diagnostic tool in AAMS of unknown etiology in children. MATERIALS AND METHODS We conducted a prospective study involving EEG assessments on children presenting with AAMS between May 2017 and October 2019. Inclusion criteria were age 1 month to 18 years and acute (<1 week) and persistent (>5 minutes) altered mental status. Patients with a known etiology of AAMS were excluded. A literature review was also performed. RESULTS Twenty patients (median age: 7.7 years, range: 0.5-15.4) were enrolled. EEG contributed to the diagnosis in 14/20 cases, and was classified as diagnostic in 9/20 and informative in 5/20. Specifically, EEG was able to identify nonconvulsive status epilepticus (NCSE) in five children and psychogenic events in four. EEG proved to be a poorly informative diagnostic tool at AAMS onset in six children; however, in five of them, it proved useful during follow-up. CONCLUSIONS Limited data exist regarding the role of EEG in children with AAMS of unknown etiology. In our population, EEG proved to be valuable tool, and was especially useful in the prompt identification of NCSE and psychogenic events.
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Affiliation(s)
- Daniela Chiarello
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- Department of Neuroscience, Neurology of Epilepsy and Movement Disorder Unit, Bambino Gesù Children's Hospital - Member of the European Reference Network EpiCARE, Roma, Italy
| | - Annalisa Perrone
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Emilia Ricci
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- Department of Health Sciences, Child Neuropsychiatry Unit, Epilepsy Center, San Paolo Hospital, University of Milan, Milan, Italy
| | - Giulia Ferrera
- Department of Health Sciences, Child Neuropsychiatry Unit, Epilepsy Center, San Paolo Hospital, University of Milan, Milan, Italy
| | - Francesca Duranti
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- Child and Adolescent Neuropsychiatry Unit, AUSL Romagna - Infermi Hospital, Rimini, Italy
| | - Silvia Bonetti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Valentina Marchiani
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Anna Fetta
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Bologna, Italy
| | - Duccio Maria Cordelli
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'Età Pediatrica, Bologna, Italy
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Luna R, Basil B, Ewbank D, Kasturiarachi BM, Mizrahi MA, Ngwenya LB, Foreman B. Clinical Impact of Standardized Interpretation and Reporting of Multimodality Neuromonitoring Data. Crit Care Explor 2024; 6:e1139. [PMID: 39120075 PMCID: PMC11319310 DOI: 10.1097/cce.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVE Evaluate the consistency and clinical impact of standardized multimodality neuromonitoring (MNM) interpretation and reporting within a system of care for patients with severe traumatic brain injury (sTBI). DESIGN Retrospective, observational historical case-control study. SETTING Single-center academic level I trauma center. INTERVENTIONS Standardized interpretation of MNM data summarized within daily reports. MEASUREMENTS MAIN RESULTS Consecutive patients with sTBI undergoing MNM were included. Historical controls were patients monitored before implementation of standardized MNM interpretation; cases were defined as patients with available MNM interpretative reports. Patient characteristics, physiologic data, and clinical outcomes were recorded, and clinical MNM reporting elements were abstracted. The primary outcome was the Glasgow Outcome Scale score 3-6 months postinjury. One hundred twenty-nine patients were included (age 42 ± 18 yr, 82% men); 45 (35%) patients were monitored before standardized MNM interpretation and reporting, and 84 (65%) patients were monitored after that. Patients undergoing standardized interpretative reporting received fewer hyperosmotic agents (3 [1-6] vs. 6 [1-8]; p = 0.04) and spent less time above an intracranial threshold of 22 mm Hg (22% ± 26% vs. 28% ± 24%; p = 0.05). The MNM interpretation cohort had a lower proportion of anesthetic days (48% [24-70%] vs. 67% [33-91%]; p = 0.02) and higher average end-tidal carbon dioxide during monitoring (34 ± 6 mm Hg vs. 32 ± 6 mm Hg; p < 0.01; d = 0.36). After controlling for injury severity, patients undergoing standardized MNM interpretation and reporting had an odds of 1.5 (95% CI, 1.37-1.59) for better outcomes. CONCLUSIONS Standardized interpretation and reporting of MNM data are a novel approach to provide clinical insight and to guide individualized critical care. In patients with sTBI, independent MNM interpretation and communication to bedside clinical care teams may result in improved intracranial pressure control, fewer medical interventions, and changes in ventilatory management. In this study, the implementation of a system for management, including standardized MNM interpretation, was associated with a significant improvement in outcome.
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Affiliation(s)
- Rudy Luna
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Barbara Basil
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Davis Ewbank
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Moshe A. Mizrahi
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Laura B. Ngwenya
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
- Collaborative for Research on Acute Neurological Injuries (CRANI), Cincinnati, OH
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Collaborative for Research on Acute Neurological Injuries (CRANI), Cincinnati, OH
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Oh A, Wusthoff CJ, Kim H. Continuous Electroencephalogram Use and Hospital Outcomes in Critically Ill Children. J Clin Neurophysiol 2024; 41:291-296. [PMID: 36893384 DOI: 10.1097/wnp.0000000000000993] [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: 06/22/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023] Open
Abstract
PURPOSE To examine the association between CEEG use and discharge status, length of hospitalization, and health care cost in a critically ill pediatric population. METHODS Four thousand three hundred forty-eight critically ill children were identified from a US nationwide administrative health claims database; 212 (4.9%) of whom underwent CEEG during admissions (January 1, 2015-june 30, 2020). Discharge status, length of hospitalization, and health care cost were compared between patients with and without CEEG use. Multiple logistic regression analyzed the association between CEEG use and these outcomes, controlling for age and underlying neurologic diagnosis. Prespecified subgroups analysis was performed for children with seizures/status epilepticus, with altered mental status and with cardiac arrest. RESULTS Compared with critically ill children without CEEG, those who underwent CEEG were likely to have shorter hospital stays than the median (OR = 0.66; 95% CI = 0.49-0.88; P = 0.004), and also total hospitalization costs were less likely to exceed the median (OR = 0.59; 95% CI = 0.45-0.79; P < 0.001). There was no difference in odds of favorable discharge status between those with and without CEEG (OR = 0.69; 95% CI = 0.41-1.08; P = 0.125). In the subgroup of children with seizures/status epilepticus, those with CEEG were less likely to have unfavorable discharge status, compared with those without CEEG (OR = 0.51; 95% CI = 0.27-0.89; P = 0.026). CONCLUSIONS Among critically ill children, CEEG was associated with shorter stay and lower costs of hospitalization but was not associated with change of favorable discharge status except the subgroup with seizures/status epilepticus.
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Affiliation(s)
- Ahyuda Oh
- Departments of Neurology and Neurological Sciences; and
| | - Courtney J Wusthoff
- Departments of Neurology and Neurological Sciences; and
- Pediatrics, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Hyunmi Kim
- Departments of Neurology and Neurological Sciences; and
- Pediatrics, Stanford University School of Medicine, Palo Alto, California, U.S.A
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Stephens CM, Mathieson SR, McNamara B, McSweeney N, O'Brien R, O'Mahony O, Boylan GB, Murray DM. Electroencephalography Quality and Application Times in a Pediatric Emergency Department Setting: A Feasibility Study. Pediatr Neurol 2023; 148:82-85. [PMID: 37690268 DOI: 10.1016/j.pediatrneurol.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/06/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Status epilepticus is the most common neurological emergency presenting to pediatric emergency departments. Nonconvulsive status epilepticus can be extremely challenging to diagnose, however, requiring electroencephalographic (EEG) confirmation for definitive diagnosis. We aimed to determine the feasibility of achieving a good-quality pediatric EEG recording within 20 minutes of presentation to the emergency department. METHODS Single-center prospective feasibility study in Cork University Hospital, Ireland, between July 2021 and June 2022. Two-channel continuous EEG was recorded from children (1) aged <16 years and (2) with Glasgow Coma Scale <11 or a reduction in baseline Glasgow Coma Scale in the case of a child with a neurodisability. RESULTS Twenty patients were included. The median age at presentation was 65.8 months (interquartile range, 23.2 to 119.0); 50% had a background diagnosis of epilepsy. The most common reason for EEG monitoring was status epilepticus (85%) followed by suspected nonconvulsive status (10%) and reduced consciousness of unknown etiology (5%). The mean length of recording was 93.1 minutes (S.D. 47.4). The mean time to application was 41.3 minutes (S.D. 11.7). The mean percent of artifact in all recordings was 19.3% (S.D. 15.9). Thirteen (65%) EEGs had <25% artifact. Artifact was higher in cases in which active airway management was ongoing. CONCLUSIONS EEG monitoring can be achieved in a pediatric emergency department setting within one hour of presentation. Overall, artifact percentage was low outside of periods of airway manipulation. Future studies are required to determine its use in early seizure detection and its support role in clinical decision-making in these patients.
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Affiliation(s)
- Carol M Stephens
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Sean R Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Brian McNamara
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Niamh McSweeney
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Department of Paediatric Neurology, Cork University Hospital, Cork, Ireland
| | - Rory O'Brien
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Olivia O'Mahony
- Department of Paediatric Neurology, Cork University Hospital, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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Sheikh Z, Selioutski O, Taraschenko O, Gilmore EJ, Westover MB, Cohen AB. Systematic Evaluation of Research Priorities in Critical Care Electroencephalography. J Clin Neurophysiol 2023; 40:426-433. [PMID: 35066530 PMCID: PMC9296700 DOI: 10.1097/wnp.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The Critical Care EEG Monitoring Research Consortium (CCEMRC) is an international research group focusing on critical care EEG and epilepsy. As CCEMRC grew to include 50+ institutions over the past decade, members met to establish research priorities. METHODS The authors used an analytical hierarchy process-based research prioritization method, adapted from an approach previously applied to a Department of Defense health-related research program. Forty-six CCEMRC members identified and scored a set of eight clinical problems (CPs) and 15 research topic areas (RTAs) at an annual CCEMRC meeting. Members scored CPs on three criteria using a five-point ordinal scale: Incidence, Impact, and Gap Size; and RTAs on four additional criteria: Niche, Feasibility, Scientific Importance, and Medical Importance, each of which was assigned a weight. The first three RTA criteria were scored using a five-point scale, and CPs were mapped to RTAs using a four-point scale. The Medical Importance score was a weighted average of its mapping scores and the CP score. Finally, a Priority score was calculated for each RTA as a product of the four RTA criteria scores. RESULTS The CPs with the highest scores were "Altered mental status" and "Long-term neurologic disability after hospital discharge." The RTAs with the highest priority scores were "Development of risk prediction tools," "Multicenter observational studies," and "Outcome prediction." CONCLUSIONS Research prioritization helped CCEMRC evaluate its current research trajectory, identify high-priority near-term research pursuits, and create a roadmap for future research plans aligned with its mission. This approach may be helpful to other academic consortia and research programs.
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Affiliation(s)
- Zubeda Sheikh
- Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, U.S.A
| | - Olga Selioutski
- Epilepsy Division, Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York, U.S.A
| | - Olga Taraschenko
- Comprehensive Epilepsy Center, Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | - Emily J Gilmore
- Division of Neurocritical Care, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
- Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Adam B Cohen
- The Johns Hopkins University Applied Physics Lab, National Health Mission Area, Laurel, Maryland, U.S.A.; and
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
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Ospina Jimenez C, Sivaswamy L, Castellucci G, Taskin B, Farooqi A, Kannikeswaran N. Yield of Neurodiagnostic Testing in Children Presenting to a Pediatric Emergency Department With Altered Mental Status. Pediatr Neurol 2023; 146:8-15. [PMID: 37379589 DOI: 10.1016/j.pediatrneurol.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/07/2023] [Accepted: 05/28/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Emergency department (ED) visits for altered mental status (AMS) in children are common. Neuroimaging is often performed to ascertain etiology, but its utility has not been well studied. Our objective is to describe the yield of neuroimaging studies in children who present to an ED with AMS. METHODS We performed a retrospective chart review of children 0-18 years of age, presenting to our PED between 2018 and 2021 with AMS. We abstracted patient demographics, physical examination, neuroimaging and EEG results, and final diagnosis. Neuroimaging and EEG studies were classified as normal or abnormal. Abnormal studies were categorized as clinically important and contributory: abnormalities that were clinically important and contributed to the etiology, clinically important but noncontributory: abnormalities that were clinically significant but did not explain the etiology, and incidental: abnormalities that were not clinically significant. RESULTS We analyzed 371 patients. The most common etiology of AMS was toxicologic (188, 51%) with neurologic causes (n = 50, 13.5%) accounting for a minority. Neuroimaging was performed in one-half (169, 45.5%) and abnormalities were noted in 44 (26%) studies. Abnormalities were clinically important and contributed to the etiologic diagnosis of AMS in 15/169 (8.9%), clinically important and noncontributory in 18/169 (10.7%), and incidental in 11/169 (6.5%). EEG was performed in 65 patients (17.5%), of which 17 (26%) were abnormal with only one being clinically important and contributory. CONCLUSIONS Though neuroimaging was performed in approximately one half of the cohort, it was contributory in a minority. Similarly, diagnostic utility of EEG in children with AMS was low.
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Affiliation(s)
| | - Lalitha Sivaswamy
- Professor of Pediatrics and Neurology, Division of Neurology, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
| | - Giovanni Castellucci
- Pediatric Neurology Resident, Children's Hospital of Michigan, Detroit, Michigan
| | - Birce Taskin
- Pediatric Neurology Resident, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- Assistant Professor Biostatistics, Clinical Research Institute CMU College of Medicine, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Professor of Pediatrics & Emergency Medicine, Division of Emergency Medicine, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
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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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Anetakis KM, Gedela S, Kochanek PM, Clark RSB, Berger RP, Fabio A, Angus DC, Watson RS, Callaway CW, Bell MJ, Sogawa Y, Fink EL. Association of EEG and Blood-Based Brain Injury Biomarker Accuracy to Prognosticate Mortality After Pediatric Cardiac Arrest: An Exploratory Study. Pediatr Neurol 2022; 134:25-30. [PMID: 35785591 DOI: 10.1016/j.pediatrneurol.2022.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/07/2022] [Accepted: 06/07/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Evaluate the accuracy of brain-based blood biomarkers neuron-specific enolase (NSE) and S100b and electroencephalography (EEG) features alone and in combination with prognosticate 6-month mortality after pediatric cardiac arrest. We hypothesized that the combination of blood brain-based biomarkers and EEG features would have superior classification accuracy of outcome versus either alone. METHODS Children (n = 58) aged between 1 week and 17 years admitted to the ICU following cardiac arrest at a tertiary care children's hopital were eligible for this secondary study. Blood NSE and S100b were measured closest to 24 hours after return of spontaneous circulation (ROSC). EEGs closest to 24 hours (median 11, interquartile range [IQR] 6 to 16 h) post-ROSC were evaluated by two epileptologists. EEG grade was informed by background frequency, amplitude, and continuity. Sleep spindles were present or absent. Mortality was assessed at six months post-ROSC. Area under the receiver operator curve (AUC) was performed for individual and combined brain-based biomarkers and EEG features. RESULTS Children were aged 2.6 (IQR 0.6 to 10.4) years, and 25 (43%) died. Children who died had increased blood NSE (49.7 [28.0 to 63.1] vs 18.2 [9.8 to 31.8] ng/mL) and S100b (0.118 [0.036 to 0.296] vs 0.012 [0.003 to 0.021] ng/mL) and poor (discontinuous or isoelectric) EEG grade (76% vs 33%) more frequently than survivors (P < 0.05). AUC for NSE to predict mortality was 0.789, and was 0.841 when combined with EEG grade and spindles. S100b AUC for mortality was 0.856 and was optimal alone. CONCLUSIONS In this exploratory study, the combination of brain-based biomarkers and EEG features may provide more accurate prognostication than either test alone after pediatric cardiac arrest.
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Affiliation(s)
- Katherine M Anetakis
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania
| | - R Scott Watson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Clifton W Callaway
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael J Bell
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Yoshimi Sogawa
- Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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9
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Bozarth XL, Ko PY, Bao H, Abend NS, Watson RS, Qu P, Dervan LA, Morgan LA, Wainwright M, McGuire JK, Novotny E. Use of Continuous EEG Monitoring and Short-Term Outcomes in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1749433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThis study aimed to compare short-term outcomes at pediatric intensive care unit (PICU) discharge in critically ill children with and without continuous electroencephalography (cEEG) monitoring. We retrospectively compared 234 patients who underwent cEEG with 2294 patients without cEEG. Propensity score matching was used to compare patients with seizures and status epilepticus between cEEG and historical cohorts. The EEG cohort had higher in-hospital mortality, worse Pediatric Cerebral Performance Category (PCPC) scores, and greater PCPC decline at discharge. In patients with status epilepticus, the PCPC decline was higher in the cEEG cohort. PCPC decline at PICU discharge was associated with cEEG monitoring in patients with status epilepticus.
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Affiliation(s)
- Xiuhua Liang Bozarth
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Pin-Yi Ko
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Hao Bao
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Nicholas S. Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Pingping Qu
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Lindsey A. Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Mark Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - John K. McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Edward Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
- Center for Integrative Brain Research, Seattle Children's Research Institute, Washington, United States
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Chen H, Atallah E, Pauldurai J, Becker A, Koubeissi M. Continuous Electroencephalogram Evaluation of Paroxysmal Events in Critically Ill Patients: Diagnostic Yield and Impact on Clinical Decision Making. Neurocrit Care 2022; 37:697-704. [PMID: 35764859 DOI: 10.1007/s12028-022-01542-y] [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: 11/17/2021] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Continuous electroencephalogram (cEEG) monitoring has been widely used in the intensive care unit (ICU) for the evaluation of patients in the ICU with altered consciousness to detect nonconvulsive seizures. We investigated the yield of cEEG when used to evaluate paroxysmal events in patients in the ICU and assessed the predictors of a diagnostic findings. The clinical impact of cEEG was also evaluated in this study. METHODS We identified patients in the ICU who underwent cEEG monitoring (> 6 h) to evaluate paroxysmal events between January 1, 2018, and December 31, 2019. We extracted patient demographics, medical history, neurological examination, brain imaging results, and the description of the paroxysmal events that necessitated the monitoring. We dichotomized the cEEG studies into those that captured habitual nonepileptic events or revealed epileptiform discharges (ictal or interictal), i.e., those considered to be of positive diagnostic yield (Y +), and those studies that did not show those findings (negative diagnostic yield, Y -). We also assessed the clinical impact of cEEG by documenting changes in administered antiseizure medication (ASM) before and after the cEEG. RESULTS We identified 159 recordings that were obtained for the indication of paroxysmal events, of which abnormal movements constituted the majority (n = 123). For the remaining events (n = 36), descriptions included gaze deviations, speech changes, and sensory changes. Twenty-nine percent (46 of 159) of the recordings were Y + , including the presence of ictal or interictal epileptiform discharges (n = 33), and captured habitual nonepileptic events (n = 13). A history of epilepsy was the only predictor of the study outcome. Detection of abnormal findings occurred within 6 h of the recording in most patients (30 of 46, 65%). Overall, cEEG studies led to 49 (31%) changes in ASM administration. The changes included dosage increases or initiation of ASM in patients with epileptiform discharges (n = 28) and reduction or elimination of ASM in patients with either habitual nonepileptic events (n = 5) or Y - cEEG studies (n = 16). CONCLUSIONS Continuous electroencephalogram monitoring is valuable in evaluating paroxysmal events, with a diagnostic yield of 29% in critically ill patients. A history of epilepsy predicts diagnostic studies. Both Y + and Y - cEEG studies may directly impact clinical decisions by leading to ASMs changes.
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Affiliation(s)
- Hai Chen
- Department of Neurology, George Washington University School of Medicine and Health Sciences, George Washington University, 2150 Pennsylvania Ave, NW, Washington, DC, 20037, USA.
| | - Eugenie Atallah
- Department of Neurology, George Washington University School of Medicine and Health Sciences, George Washington University, 2150 Pennsylvania Ave, NW, Washington, DC, 20037, USA
| | - Jennifer Pauldurai
- Department of Neurology, George Washington University School of Medicine and Health Sciences, George Washington University, 2150 Pennsylvania Ave, NW, Washington, DC, 20037, USA
| | - Andrew Becker
- Department of Neurology, George Washington University School of Medicine and Health Sciences, George Washington University, 2150 Pennsylvania Ave, NW, Washington, DC, 20037, USA
| | - Mohamad Koubeissi
- Department of Neurology, George Washington University School of Medicine and Health Sciences, George Washington University, 2150 Pennsylvania Ave, NW, Washington, DC, 20037, USA
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Waak M, Gibbons K, Sparkes L, Harnischfeger J, Gurr S, Schibler A, Slater A, Malone S. Real-time seizure detection in paediatric intensive care patients: the RESET child brain protocol. BMJ Open 2022; 12:e059301. [PMID: 36691237 PMCID: PMC9171209 DOI: 10.1136/bmjopen-2021-059301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Approximately 20%-40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection. METHODS AND ANALYSIS This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as 'at risk of seizures' will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs. ETHICS AND DISSEMINATION The study has received approval by the Children's Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.
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Affiliation(s)
- Michaela Waak
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Centre for Children's Health Research, Brisbane, Queensland, Australia
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Louise Sparkes
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Jane Harnischfeger
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Sandra Gurr
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia
| | - Anthony Slater
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Stephen Malone
- The University of Queensland, Saint Lucia, Queensland, Australia
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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12
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Taran S, Ahmed W, Pinto R, Bui E, Prisco L, Hahn CD, Englesakis M, McCredie VA. Educational initiatives for electroencephalography in the critical care setting: a systematic review and meta-analysis. Can J Anaesth 2021; 68:1214-1230. [PMID: 33709264 PMCID: PMC7952081 DOI: 10.1007/s12630-021-01962-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE We systematically reviewed existing critical care electroencephalography (EEG) educational programs for non-neurologists, with the primary goal of reporting the content covered, methods of instruction, overall duration, and participant experience. Our secondary goals were to assess the impact of EEG programs on participants' core knowledge, and the agreement between non-experts and experts for seizure identification. SOURCE Major databases were searched from inception to 30 August 2020. Randomized controlled trials, cohort studies, and descriptive studies were all considered if they reported an EEG curriculum for non-neurologists in a critical care setting. Data were presented thematically for the qualitative primary outcome and a meta-analysis using a random effects model was performed for the quantitative secondary outcomes. PRINCIPAL FINDINGS Twenty-nine studies were included after reviewing 7,486 citations. Twenty-two studies were single centre, 17 were from North America, and 16 were published after 2016. Most EEG studies were targeted to critical care nurses (17 studies), focused on processed forms of EEG with amplitude-integrated EEG being the most common (15 studies), and were shorter than one day in duration (24 studies). In pre-post studies, EEG programs significantly improved participants' knowledge of tested material (standardized mean change, 1.79; 95% confidence interval [CI], 0.86 to 2.73). Agreement for seizure identification between non-experts and experts was moderate (Cohen's kappa = 0.44; 95% CI, 0.27 to 0.60). CONCLUSIONS It is feasible to teach basic EEG to participants in critical care settings from different clinical backgrounds, including physicians and nurses. Brief training programs can enable bedside providers to recognize high-yield abnormalities such as non-convulsive seizures.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Li Ka Shing Knowledge Institute, University of Toronto, 204 Victoria Street, 4th Floor Room 411, Toronto, ON, M5B 1T8, Canada.
| | - Wael Ahmed
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Esther Bui
- Division of Neurology, University Health Network, Toronto, ON, Canada
| | - Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Li Ka Shing Knowledge Institute, University of Toronto, 204 Victoria Street, 4th Floor Room 411, Toronto, ON, M5B 1T8, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
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Butler E, Mills N, J P Alix J, Hart AR. Knowledge and attitudes of critical care providers towards neurophysiological monitoring, seizure diagnosis, and treatment. Dev Med Child Neurol 2021; 63:976-983. [PMID: 33913148 DOI: 10.1111/dmcn.14907] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
AIM To explore the attitudes of paediatric intensive care unit (PICU) health care professionals towards diagnosis and neurophysiological monitoring of seizures. METHOD This study used an explanatory sequential mixed-methods approach, interconnecting quantitative and qualitative features, comprising questionnaires and interviews, with equal weighting between stages, of health care professionals working in UK PICUs. Interview data were analysed using thematic analysis and triangulated with questionnaire data. RESULTS Seventy-two questionnaires were returned: 49 out of 60 (71.0%) of respondents reported that seizures were extremely hard or somewhat hard to diagnose in a critically ill child, and 81.2% had seen misdiagnosis occur. Thematic analysis revealed two main themes: (1) feeling out of control when faced with 'grey areas'; and (2) regaining control, which compromised three subthemes: aggressive intervention, accurate diagnosis, and eschewing diagnosis. INTERPRETATION Health care professionals find accurate diagnosis of seizures difficult, particularly in sedated/paralysed children and those with chronic neurological disorders. They report they would like better educational opportunities on discriminating between epileptic and non-epileptic events to improve their confidence. Professionals want routine neurophysiological monitoring that can be applied and interpreted at the bedside throughout the day to regain a sense of control over their patient, direct treatment appropriately, and, potentially, improve outcomes, but report appropriate training and peer review are essential if it is to be introduced into routine care. What this study adds Paediatric intensive care unit (PICU) staff feel out of control when faced with diagnosing seizures. Neurophysiological monitoring is wanted to help diagnosis and treatment. Amplitude-integrated electroencephalography is the preferred, pragmatic tool by PICU staff.
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Affiliation(s)
- Evie Butler
- University of Sheffield Medical School, Sheffield, UK
| | - Nicholas Mills
- Department of Paediatric Intensive Care Unit, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - James J P Alix
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Anthony R Hart
- Department of Paediatric and Neonatal Neurology, Ryegate Children's Centre, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Abstract
INTRODUCTION Evidence for continuous EEG monitoring in the pediatric intensive care unit (PICU) is increasing. However, 24/7 access to EEG is not routinely available in most centers, and clinical management is often informed by more limited EEG resources. The experience of EEG was reviewed in a tertiary PICU where 24/7 EEG cover is unavailable. METHODS Retrospective EEG and clinical review of 108 PICU patients. Correlations were carried out between EEG and clinical variables including mortality. The role of EEG in clinical decision making was documented. RESULTS One hundred ninety-six EEGs were carried out in 108 PICU patients over 2.5 years (434 hours of recording). After exclusion of 1 outlying patient with epileptic encephalopathy, 136 EEGs (median duration, 65 minutes; range, 20 minutes to 4 hours 40 minutes) were included. Sixty-two patients (57%) were less than 12 months old. Seizures were detected in 18 of 107 patients (17%); 74% of seizures were subclinical; 72% occurred within the first 30 minutes of recording. Adverse EEG findings were associated with high mortality. Antiepileptic drug use was high in the studied population irrespective of EEG seizure detection. Prevalence of epileptiform discharges and EEG seizures diminished with increasing levels of sedation. CONCLUSIONS EEG provides important diagnostic information in a large proportion of PICU patients. In the absence of 24/7 EEG availability, empirical antiepileptic drug utilization is high.
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15
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Wang Z, Zhang P, Zhou W, Zhou X, Shi Y, Cheng X, Lin Z, Xia S, Zhou W, Cheng G. Electroencephalography monitoring in the neonatal intensive care unit: a Chinese perspective. Transl Pediatr 2021; 10:552-559. [PMID: 33850813 PMCID: PMC8039787 DOI: 10.21037/tp-20-340] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Electroencephalography (EEG) is an accessible technique for bedside monitoring of the cerebral function in the neonatal intensive care unit (NICU). The popularization of EEG in the field of newborns in China is relatively late compared with western countries. To learn more about current practices and improvement of EEG monitoring, we conducted a survey to describe current utilization of EEG in NICU in China. METHODS A cross-sectional electronic survey with 21-items about EEG using in NICU was administered for pediatricians in China on the official website of "Questionnaire Star". RESULTS A total of 251 participants were involved, in which 64% of them reported using EEG. EEG was employed in NICUs of Children's hospitals (97%), and grade III, class A hospitals (69%). Besides, neonatal encephalopathy and suspected seizures were the most common indications for use. In clinical practice, the vast majority of physicians managed their patients on the basis of EEG (93%). Pediatricians prefer to use conventional video-EEG (cEEG) to detect seizures and make the diagnosis of encephalopathy. Both amplitude integrated EEG (aEEG) (78%) and cEEG (56%) were mainly interpreted by neonatologists. However, only 56% of respondents had ever taken a formal EEG training course. Overall, 96% of the respondents reported that they would be interested in attending an education session on EEG in the NICU. aEEG interpretation was the most interesting part to learn (81%). For those who were not using EEG, cost (43%) and difficulty interpretation (30%) were reported as barriers to use. CONCLUSIONS The utilization rate of EEG in NICU in China is significantly lower than the international level. There is an urgent need for standardized training and financial support for neonatologists in the use of EEG and interpretation of aEEG results.
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Affiliation(s)
- Zheng Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenlang Lin
- Department of Neonatology, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shiwen Xia
- Department of Neonatology, Maternal and Child Hospital of Hubei Province, Wuhan, China
| | - Wei Zhou
- Department of Neonatology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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Mizuguchi M, Ichiyama T, Imataka G, Okumura A, Goto T, Sakuma H, Takanashi JI, Murayama K, Yamagata T, Yamanouchi H, Fukuda T, Maegaki Y. Guidelines for the diagnosis and treatment of acute encephalopathy in childhood. Brain Dev 2021; 43:2-31. [PMID: 32829972 DOI: 10.1016/j.braindev.2020.08.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022]
Abstract
The cardinal symptom of acute encephalopathy is impairment of consciousness of acute onset during the course of an infectious disease, with duration and severity meeting defined criteria. Acute encephalopathy consists of multiple syndromes such as acute necrotizing encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and clinically mild encephalitis/encephalopathy with reversible splenial lesion. Among these syndromes, there are both similarities and differences. In 2016, the Japanese Society of Child Neurology published 'Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood', which made recommendations and comments on the general aspects of acute encephalopathy in the first half, and on individual syndromes in the latter half. Since the guidelines were written in Japanese, this review article describes extracts from the recommendations and comments in English, in order to introduce the essence of the guidelines to international clinicians and researchers.
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Affiliation(s)
- Masashi Mizuguchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Takashi Ichiyama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Pediatrics, Tsudumigaura Medical Center for Children with Disabilities, Yamaguchi, Japan
| | - George Imataka
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
| | - Akihisa Okumura
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Aichi Medical University, Aichi, Japan
| | - Tomohide Goto
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Division of Neurology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hiroshi Sakuma
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Jun-Ichi Takanashi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Kei Murayama
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Takanori Yamagata
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Hideo Yamanouchi
- Committee for the Compilation of Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood, Japanese Society of Child Neurology, Tokyo, Japan; Department of Pediatrics, Comprehensive Epilepsy Center, Saitama Medical University, Saitama, Japan
| | - Tokiko Fukuda
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan; Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan
| | - Yoshihiro Maegaki
- Committee for the Integration of Guidelines, Japanese Society of Child Neurology, Tokyo, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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Katyal N, Singh I, Narula N, Idiculla PS, Premkumar K, Beary JM, Nattanmai P, Newey CR. Continuous Electroencephalography (CEEG) in Neurological Critical Care Units (NCCU): A Review. Clin Neurol Neurosurg 2020; 198:106145. [PMID: 32823186 DOI: 10.1016/j.clineuro.2020.106145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/20/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Nakul Katyal
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Ishpreet Singh
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Naureen Narula
- Staten Island University Hospital, Department of Pulmonary- critical Care Medicine, 475 Seaview Avenue Staten Island, NY, 10305, United States.
| | - Pretty Sara Idiculla
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Keerthivaas Premkumar
- University of Missouri, Department of biological sciences, Columbia, MO 65211, United States.
| | - Jonathan M Beary
- A. T. Still University, Department of Neurobehavioral Sciences, Kirksville, MO, United States.
| | - Premkumar Nattanmai
- University of Missouri, Department of Neurology, 5 Hospital Drive, CE 540, United States.
| | - Christopher R Newey
- Cleveland clinic Cerebrovascular center, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
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Ghossein J, Alnaji F, Webster RJ, Bulusu S, Pohl D. Continuous EEG in a Pediatric Intensive Care Unit: Adherence to Monitoring Criteria and Barriers to Adequate Implementation. Neurocrit Care 2020; 34:519-528. [PMID: 32696100 DOI: 10.1007/s12028-020-01053-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Subclinical seizures are common in critically ill children and are best detected by continuous EEG (cEEG) monitoring. Timely detection of seizures requires pediatric intensive care unit (PICU) physicians to identify patients at risk of seizures and request cEEG monitoring. A recent consensus statement from the American Clinical Neurophysiology Society (ACNS) outlines the indications for cEEG monitoring in critically ill patients. However, adherence to these cEEG monitoring criteria among PICU physicians is unknown. Our project had two goals: 1. To assess adherence to cEEG monitoring indications and barriers toward their implementation; 2. To improve compliance with the ACNS cEEG monitoring criteria in our PICU. METHODS This is a single-institution study. A total of 234 PICU admissions (183 unique patients) were studied. A 6-month retrospective chart review identified PICU patients meeting ACNS criteria for cEEG monitoring, and patients for whom monitoring was requested. This was followed by an 8-week quality improvement project. During this mentorship period, a didactic 15-min lecture and summary handouts regarding the ACNS indications for cEEG monitoring were provided to all PICU physicians. Requests for cEEG monitoring during the mentorship period were compared to baseline adherence to cEEG monitoring recommendations, and barriers toward timely cEEG monitoring were assessed. RESULTS Nearly every fifth PICU patient met cEEG monitoring indications, and prevalences of patients meeting those indications were similar in the retrospective and the prospective mentorship period (18% vs. 19%). Almost all patients (98%) requiring cEEG as per ACNS criteria met the indication for monitoring already at the time of their PICU admission. During the retrospective period, 23% of patients meeting ACNS criteria had a request for cEEG monitoring, which increased to 83% during the mentorship period. The median delay to cEEG initiation was 16.7 h during the mentorship period, largely due to limited hours of EEG technician availability. Electrographic seizures were identified in 36% of patients monitored, all within the first 120 min of cEEG recording. The majority (79%) of cEEGs informed clinical management. CONCLUSIONS A brief teaching intervention supplemented by pictographic handouts significantly increased adherence to cEEG monitoring recommendations, and cEEGs guided clinical management. However, there were long delays to cEEG initiation. In order to promptly recognize subclinical seizures in critically ill children, we strongly advocate for a routine screening for cEEG monitoring indications as part of the PICU admission process, and a care model allowing for cEEG initiation around-the-clock.
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Affiliation(s)
- Jamie Ghossein
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Fuad Alnaji
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.,CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Richard J Webster
- CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Srinivas Bulusu
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Daniela Pohl
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada. .,CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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19
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Current Status of Continuous Electroencephalographic Monitoring in Critically Ill Children. Pediatr Neurol 2019; 101:11-17. [PMID: 31493974 DOI: 10.1016/j.pediatrneurol.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/13/2019] [Accepted: 07/26/2019] [Indexed: 11/21/2022]
Abstract
The utilization of continuous electroencephalographic monitoring in critical care units has increased significantly, and several consensus statements and guidelines have been published. The use of critical care electroencephalographic monitoring has become a standard of care in many centers in the United States and other countries. The most common indication is to detect electrographic seizures and status epilepticus. Other indications include monitoring treatment efficacy in patients with electrographic seizures and status epilepticus, evaluating the degree of disturbance of function in patients with encephalopathy, monitoring brain function in patients treated with sedation and neuromuscular blocking agents, and event characterization. The urgent initiation of critical care electroencephalographic monitoring is recommended in certain clinical populations, but varies among institutions. The consensus among neurologists is to start treatment after identifying electrographic seizures or electrographic status epilepticus with or without clinical signs. However, the optimal treatment of nonconvulsive and electrographic-only seizures remains controversial. Critical care electroencephalographic monitoring has significant impact on clinical management, but there is lack of clear evidence that treatment guided by critical care electroencephalographic monitoring leads to improvement of clinical and neurodevelopmental outcome. There are substantial discrepancies among institutions on personnel and technical support used for critical care electroencephalographic monitoring. The optimal critical care electroencephalographic monitoring team should include electroencephalographers with experience in critical care electroencephalographic monitoring interpretation and appropriately trained technologists certified in electroencephalography by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists specializing in critical care electroencephalographic monitoring or long-term monitoring.
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Yamaguchi H, Nagase H, Nishiyama M, Tokumoto S, Ishida Y, Tomioka K, Tanaka T, Fujita K, Toyoshima D, Nishimura N, Kurosawa H, Nozu K, Maruyama A, Tanaka R, Iijima K. Nonconvulsive Seizure Detection by Reduced-Lead Electroencephalography in Children with Altered Mental Status in the Emergency Department. J Pediatr 2019; 207:213-219.e3. [PMID: 30528574 DOI: 10.1016/j.jpeds.2018.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/04/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the proportion of children presenting to the emergency department (ED) with altered mental status who demonstrate nonconvulsive seizures on reduced-lead electroencephalography (EEG), and to further investigate the characteristics, treatment, and outcomes in these patients compared with patients without nonconvulsive seizures. STUDY DESIGN In this retrospective cohort study, we reviewed the database and medical records of pediatric patients (aged <18 years) in a single ED between May 1, 2016, and April 30, 2018. We first determined the proportion of nonconvulsive seizures among patients with altered mental status (Glasgow Coma Scale <15). We then compared the clinical presentation, demographic data, clinical diagnosis, EEG results, treatment, and outcomes of patients with altered mental status with nonconvulsive seizures and those without nonconvulsive seizures. RESULTS In total, 16.9% of the patients with altered mental status (41 of 242; 95% CI, 12.2%-21.6%) evaluated by EEG had detectable nonconvulsive seizure, equivalent to 4.4% (41 of 932) of all patients with altered mental status presenting at our hospital. More than 80% of patients monitored for nonconvulsive seizures had a previous history of seizures, often febrile. Patients with nonconvulsive seizures were older (median, 68.5 vs 36.1 months) and had a higher Pediatric Cerebral Performance Category score at presentation (median, 2.0 vs 1.0). In addition, the proportion of patients admitted to the intensive care unit was significantly higher in the patients with nonconvulsive seizures (30.3% vs 15.0%). However, total duration of hospitalization, neurologic sequelae, and 30-day mortality rate did not differ between the 2 groups. CONCLUSIONS A relatively high percentage of pediatric patients with altered mental status in the ED experience nonconvulsive seizures. The use of reduced-lead EEG monitoring in the ED might facilitate the recognition and treatment of nonconvulsive seizures, especially among patients with a history of seizures.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tsukasa Tanaka
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kyoko Fujita
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Daisaku Toyoshima
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Noriyuki Nishimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Ryojiro Tanaka
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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21
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Araki T. Pediatric Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Hill CE, Blank LJ, Thibault D, Davis KA, Dahodwala N, Litt B, Willis AW. Continuous EEG is associated with favorable hospitalization outcomes for critically ill patients. Neurology 2018; 92:e9-e18. [PMID: 30504428 DOI: 10.1212/wnl.0000000000006689] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/29/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To characterize continuous EEG (cEEG) use patterns in the critically ill and to determine the association with hospitalization outcomes for specific diagnoses. METHODS We performed a retrospective cross-sectional study with National Inpatient Sample data from 2004 to 2013. We sampled hospitalized adult patients who received intensive care and then compared patients who underwent cEEG to those who did not. We considered diagnostic subgroups of seizure/status epilepticus, subarachnoid or intracerebral hemorrhage, and altered consciousness. Outcomes were in-hospital mortality, hospitalization cost, and length of stay. RESULTS In total, 7,102,399 critically ill patients were identified, of whom 22,728 received cEEG. From 2004 to 2013, the proportion of patients who received cEEG increased from 0.06% (95% confidence interval [CI] 0.03%-0.09%) to 0.80% (95% CI 0.62%-0.98%). While the cEEG cohort appeared more ill, cEEG use was associated with reduced in-hospital mortality after adjustment for patient and hospital characteristics (odds ratio [OR] 0.83, 95% CI 0.75-0.93, p < 0.001). This finding held for the diagnoses of subarachnoid or intracerebral hemorrhage and for altered consciousness but not for the seizure/status epilepticus subgroup. Cost and length of hospitalization were increased for the cEEG cohort (OR 1.17 and OR 1.11, respectively, p < 0.001). CONCLUSIONS There was a >10-fold increase in cEEG use from 2004 to 2013. However, this procedure may still be underused; cEEG was associated with lower in-hospital mortality but used for only 0.3% of the critically ill population. While administrative claims analysis supports the utility of cEEG for critically ill patients, our findings suggest variable benefit by diagnosis, and investigation with greater clinical detail is warranted.
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Affiliation(s)
- Chloe E Hill
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia.
| | - Leah J Blank
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Dylan Thibault
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Kathryn A Davis
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Nabila Dahodwala
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Brian Litt
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Allison W Willis
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
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Clinical characteristics of acute encephalopathy with acute brain swelling: A peculiar type of acute encephalopathy. Brain Dev 2018; 40:792-798. [PMID: 29885875 DOI: 10.1016/j.braindev.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Acute encephalopathy has been observed with acute brain swelling (ABS) that is characterized by rapid progression to whole-brain swelling. The objective of this study was to describe the clinical characteristics of ABS. METHODS We encountered four patients with ABS and retrospectively investigated their clinical data with a medical chart review. RESULTS Three patients had seizure clustering or status epilepticus in the clinical course. Signs of elevated intracranial pressure (ICP) appeared 3-9 h after the first convulsive attack in three patients. In all patients, signs of brainstem involvement appeared 1-8 h after signs of elevated ICP. Mild hyponatremia that progressed after signs of elevated ICP appeared was noted in three patients. Brain CT revealed mild brain swelling in the initial phase, which rapidly progressed to whole-brain swelling. No focal abnormalities were detected on brain MRI in one patient. Continuous electroencephalography was initially normal, but in two patients, high-amplitude slow waves appeared with rapid changes before signs of brainstem involvement. Although recovery was achieved without sequelae in two patients, outcome was fatal for the other two. CONCLUSIONS The pathogenesis of ABS has yet to be clarified, but clinical features in our patients are not consistent with any established subtypes of acute encephalopathy. Therefore, we believe that ABS should be recognized as a new type of acute encephalopathy.
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24
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Vasquez A, Farias-Moeller R, Tatum W. Pediatric refractory and super-refractory status epilepticus. Seizure 2018; 68:62-71. [PMID: 29941225 DOI: 10.1016/j.seizure.2018.05.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/17/2018] [Accepted: 05/19/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To summarize the available evidence related to pediatric refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE), with emphasis on epidemiology, etiologies, therapeutic approaches, and clinical outcomes. METHODS Narrative review of the medical literature using MEDLINE database. RESULTS RSE is defined as status epilepticus (SE) that fails to respond to adequately used first- and second-line antiepileptic drugs. SRSE occurs when SE persist for 24 h or more after administration of anesthesia, or recurs after its withdrawal. RSE and SRSE represent complex neurological emergencies associated with long-term neurological dysfunction and high mortality. Challenges in management arise as the underlying etiology is not always promptly recognized and therapeutic options become limited with prolonged seizures. Treatment decisions mainly rely on case series or experts' opinions. The comparative effectiveness of different treatment strategies has not been evaluated in large prospective series or randomized clinical trials. Continuous infusion of anesthetic agents is the most common treatment for RSE and SRSE, although many questions on optimal dosing and rate of administration remain unanswered. The use of non-pharmacological therapies is documented in case series or reports with low level of evidence. In addition to neurological complications resulting from prolonged seizures, children with RSE/SRSE often develop systemic complications associated with polypharmacy and prolonged hospital stay. CONCLUSION RSE and SRSE are neurological emergencies with limited therapeutic options. Multi-national collaborative efforts are desirable to evaluate the safety and efficacy of current RSE/SRSE therapies, and potentially impact patients' outcomes.
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Affiliation(s)
- Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Raquel Farias-Moeller
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - William Tatum
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
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25
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Stevenson NJ, Lauronen L, Vanhatalo S. The effect of reducing EEG electrode number on the visual interpretation of the human expert for neonatal seizure detection. Clin Neurophysiol 2018; 129:265-270. [DOI: 10.1016/j.clinph.2017.10.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/02/2017] [Accepted: 10/19/2017] [Indexed: 11/15/2022]
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26
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Struck AF, Osman G, Rampal N, Biswal S, Legros B, Hirsch LJ, Westover MB, Gaspard N. Time-dependent risk of seizures in critically ill patients on continuous electroencephalogram. Ann Neurol 2017; 82:177-185. [PMID: 28681492 DOI: 10.1002/ana.24985] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/12/2017] [Accepted: 06/19/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Find the optimal continuous electroencephalographic (CEEG) monitoring duration for seizure detection in critically ill patients. METHODS We analyzed prospective data from 665 consecutive CEEGs, including clinical factors and time-to-event emergence of electroencephalographic (EEG) findings over 72 hours. Clinical factors were selected using logistic regression. EEG risk factors were selected a priori. Clinical factors were used for baseline (pre-EEG) risk. EEG findings were used for the creation of a multistate survival model with 3 states (entry, EEG risk, and seizure). EEG risk state is defined by emergence of epileptiform patterns. RESULTS The clinical variables of greatest predictive value were coma (31% had seizures; odds ratio [OR] = 1.8, p < 0.01) and history of seizures, either remotely or related to acute illness (34% had seizures; OR = 3.0, p < 0.001). If there were no epileptiform findings on EEG, the risk of seizures within 72 hours was between 9% (no clinical risk factors) and 36% (coma and history of seizures). If epileptiform findings developed, the seizure incidence was between 18% (no clinical risk factors) and 64% (coma and history of seizures). In the absence of epileptiform EEG abnormalities, the duration of monitoring needed for seizure risk of <5% was between 0.4 hours (for patients who are not comatose and had no prior seizure) and 16.4 hours (comatose and prior seizure). INTERPRETATION The initial risk of seizures on CEEG is dependent on history of prior seizures and presence of coma. The risk of developing seizures on CEEG decays to <5% by 24 hours if no epileptiform EEG abnormalities emerge, independent of initial clinical risk factors. Ann Neurol 2017;82:177-185.
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Affiliation(s)
- Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI
| | - Gamaleldin Osman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Nishi Rampal
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Benjamin Legros
- Department of Neurology, Free University of Brussels, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Nicolas Gaspard
- Department of Neurology, Free University of Brussels, Brussels, Belgium
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27
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Baldassano SN, Brinkmann BH, Ung H, Blevins T, Conrad EC, Leyde K, Cook MJ, Khambhati AN, Wagenaar JB, Worrell GA, Litt B. Crowdsourcing seizure detection: algorithm development and validation on human implanted device recordings. Brain 2017; 140:1680-1691. [PMID: 28459961 DOI: 10.1093/brain/awx098] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/26/2017] [Indexed: 11/14/2022] Open
Abstract
There exist significant clinical and basic research needs for accurate, automated seizure detection algorithms. These algorithms have translational potential in responsive neurostimulation devices and in automatic parsing of continuous intracranial electroencephalography data. An important barrier to developing accurate, validated algorithms for seizure detection is limited access to high-quality, expertly annotated seizure data from prolonged recordings. To overcome this, we hosted a kaggle.com competition to crowdsource the development of seizure detection algorithms using intracranial electroencephalography from canines and humans with epilepsy. The top three performing algorithms from the contest were then validated on out-of-sample patient data including standard clinical data and continuous ambulatory human data obtained over several years using the implantable NeuroVista seizure advisory system. Two hundred teams of data scientists from all over the world participated in the kaggle.com competition. The top performing teams submitted highly accurate algorithms with consistent performance in the out-of-sample validation study. The performance of these seizure detection algorithms, achieved using freely available code and data, sets a new reproducible benchmark for personalized seizure detection. We have also shared a 'plug and play' pipeline to allow other researchers to easily use these algorithms on their own datasets. The success of this competition demonstrates how sharing code and high quality data results in the creation of powerful translational tools with significant potential to impact patient care.
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Affiliation(s)
- Steven N Baldassano
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA.,Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Benjamin H Brinkmann
- Mayo Systems Electrophysiology Laboratory, Departments of Neurology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA.,Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
| | - Hoameng Ung
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA.,Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tyler Blevins
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA.,Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Erin C Conrad
- Department of Neurology, University of Pennsylvania, PA, USA
| | | | - Mark J Cook
- St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Ankit N Khambhati
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA.,Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Joost B Wagenaar
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA.,Department of Neurology, University of Pennsylvania, PA, USA
| | - Gregory A Worrell
- Mayo Systems Electrophysiology Laboratory, Departments of Neurology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA.,Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
| | - Brian Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA.,Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA.,Department of Neurology, University of Pennsylvania, PA, USA
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28
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Moura LMVR, Carneiro TS, Kwasnik D, Moura VF, Blodgett CS, Cohen J, McKenna Guanci M, Hoch DB, Hsu J, Cole AJ, Westover MB. cEEG electrode-related pressure ulcers in acutely hospitalized patients. Neurol Clin Pract 2017; 7:15-25. [PMID: 28243502 DOI: 10.1212/cpj.0000000000000312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pressure ulcers resulting from continuous EEG (cEEG) monitoring in hospitalized patients have gained attention as a preventable medical complication. We measured their incidence and risk factors. METHODS We performed an observational investigation of cEEG-electrode-related pressure ulcers (EERPU) among acutely ill patients over a 22-month period. Variables analyzed included age, sex, monitoring duration, hospital location, application methods, vasopressor usage, nutritional status, skin allergies, fever, and presence/severity of EERPU. We examined risk for pressure ulcers vs monitoring duration using Kaplan-Meyer survival analysis, and performed multivariate risk assessment using Cox proportional hazard model. RESULTS Among 1,519 patients, EERPU occurred in 118 (7.8%). Most (n = 109, 92.3%) consisted of hyperemia only without skin breakdown. A major predictor was monitoring duration, with 3-, 5-, and 10-day risks of 16%, 32%, and 60%, respectively. Risk factors included older age (mean age 60.65 vs 50.3, p < 0.01), care in an intensive care unit (9.37% vs 5.32%, p < 0.01), lack of a head wrap (8.31% vs 27.3%, p = 0.02), use of vasopressors (16.7% vs 9.64%, p < 0.01), enteral feeding (11.7% vs 5.45%, p = 0.04), and fever (18.4% vs 9.3%, p < 0.01). Elderly patients (71-80 years) were at higher risk (hazard ratio 6.84 [1.95-24], p < 0.01), even after accounting for monitoring time and other pertinent variables in multivariate analysis. CONCLUSIONS EERPU are uncommon and generally mild. Elderly patients and those with more severe illness have higher risk of developing EERPU, and the risk increases as a function of monitoring duration.
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Affiliation(s)
- Lidia M V R Moura
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Thiago S Carneiro
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - David Kwasnik
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Valdery F Moura
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Christine S Blodgett
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Joseph Cohen
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Mary McKenna Guanci
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Daniel B Hoch
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - John Hsu
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - Andrew J Cole
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
| | - M Brandon Westover
- Massachusetts General Hospital (LMVRM, TSC, DK, VFM, JC, MKG, DBH, JH, AJC, MBW), Boston; Physicians Ancillary Services, LLC (CSB), Rocky Hill, CT; and Labouré College (CSB), Milton, MA
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29
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Khawaja AM, Wang G, Cutter GR, Szaflarski JP. Continuous Electroencephalography (cEEG) Monitoring and Outcomes of Critically Ill Patients. Med Sci Monit 2017; 23:649-658. [PMID: 28160596 PMCID: PMC5304944 DOI: 10.12659/msm.900826] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background It is not clear whether performing continuous EEG (cEEG) in critically ill patients during intensive care unit (ICU) treatment affects outcomes at discharge. Material/Methods We prospectively matched 234 patients who received cEEG (cases) by admission diagnosis and sex to 234 patients who did not receive cEEG (controls) and followed them until discharge. Patients admitted due to seizures were excluded. The primary measures of outcome were Glasgow Coma Scale at Discharge (GCSD) and disposition at discharge, and the secondary measures of outcome were AED modifications, Glasgow Outcomes Scale, and Modified-Rankin Scale. These outcomes were compared between the cases and controls. Results Some differences in primary outcome measures between the groups emerged on univariate analyses, but these differences were small and not significant after controlling for covariates. Cases had longer ICU stays (p=0.002) and lower admission GCS (p=0.01) but similar GCSD (p=0.10). Of the secondary outcome measures, the mean (SD) number of AED modifications for cases was 2.2±3.1 compared to 0.4±0.8 for controls (p<0.0001); 170 (72.6%) cases had at least 1 AED modification compared to only 56 (24.1%) of the controls (p<0.0001). Conclusions Performing cEEG did not improve discharge outcome but it significantly influenced AED prescription patterns. Further studies assessing long-term outcomes are needed to better define the role of cEEG in this patient population.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, University of Alabama at Birmingham (UAB) Hospital, Birmingham, AL, USA.,Department of Neurology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Guoqiao Wang
- Department of Biostatistics, University of Alabama at Birmingham (UAB) Hospital, Birmingham, AL, USA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham (UAB) Hospital, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham (UAB) Hospital, Birmingham, AL, USA.,University of Alabama at Birmingham (UAB) Epilepsy Center, Birmingham, AL, USA
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30
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Alvarez V, Rodriguez Ruiz AA, LaRoche S, Hirsch LJ, Parres C, Voinescu PE, Fernandez A, Petroff OA, Rampal N, Haider HA, Lee JW. The use and yield of continuous EEG in critically ill patients: A comparative study of three centers. Clin Neurophysiol 2017; 128:570-578. [PMID: 28231475 DOI: 10.1016/j.clinph.2017.01.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/07/2016] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Continuous EEG (cEEG) monitoring of critically ill patients has gained widespread use, but there is substantial reported variability in its use. We analyzed cEEG and antiseizure drug (ASD) usage at three high volume centers. METHODS We utilized a multicenter cEEG database used daily as a clinical reporting tool in three tertiary care sites (Emory Hospital, Brigham and Women's Hospital and Yale - New Haven Hospital). We compared the cEEG usage patterns, seizure frequency, detection of rhythmic/periodic patterns (RPP), and ASD use between the sites. RESULTS 5792 cEEG sessions were analyzed. Indication for cEEG monitoring and recording duration were similar between the sites. Seizures detection rate was nearly identical between the three sites, ranging between 12.3% and 13.6%. Median time to first seizure and detection rate of RPPs were similar. There were significant differences in doses of levetiracetam, valproic acid, and lacosamide used between the three sites. CONCLUSIONS There was remarkable uniformity in seizure detection rates within three high volume centers. In contrast, dose of ASD used frequently differed between the three sites. SIGNIFICANCE These large volume data are in line with recent guidelines regarding cEEG use. Difference in ASD use suggests discrepancies in how cEEG results influence patient management.
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Affiliation(s)
- Vincent Alvarez
- Department of Neurology, Hôpital du Valais, Sion, Switzerland; Department of Clinical Neurosciences, CHUV and University of Lausanne, Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | | | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Parres
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Paula E Voinescu
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Andres Fernandez
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ognen A Petroff
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Nishi Rampal
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Gupta A. Continuous Video EEG in Neonates: Emerging Trends and Paradigms. Epilepsy Curr 2016; 16:386-388. [PMID: 27857618 PMCID: PMC5106100 DOI: 10.5698/1535-7511-16.6.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Billakota S, Sinha SR. Utility of Continuous EEG Monitoring in Noncritically lll Hospitalized Patients. J Clin Neurophysiol 2016; 33:421-425. [DOI: 10.1097/wnp.0000000000000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Could EEG Monitoring in Critically Ill Children Be a Cost-effective Neuroprotective Strategy? J Clin Neurophysiol 2016; 32:486-94. [PMID: 26057408 DOI: 10.1097/wnp.0000000000000198] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Electrographic status epilepticus (ESE) in critically ill children is associated with unfavorable functional outcomes, but identifying candidates for ESE management requires resource-intense EEG monitoring. A cost-effectiveness analysis was performed to estimate how much ESE identification and management would need to improve patient outcomes to make EEG monitoring strategies a good value. METHODS A decision tree was created to examine the relationships among variables important to deciding whether to perform EEG monitoring. Variable costs were estimated from their component parts, outcomes were estimated in quality-adjusted life-years, and incremental cost-effectiveness ratios were calculated to compare the relative values using four alternative EEG monitoring strategies that varied by monitoring duration. RESULTS Forty-eight hours of EEG monitoring would be worth its cost if ESE identification and management improved patient outcomes by ≥7%. If ESE identification and management improved patient outcomes by 3% to 6%, then 24 or 48 hours of EEG monitoring would be worth the cost depending on how much decision makers were willing to pay per quality-adjusted life-year gained. If ESE identification and management improved outcomes by as little as 3%, then 24 hours of EEG monitoring would be worth the cost. CONCLUSIONS EEG monitoring has the potential to be cost-effective if ESE identification and management improves patient outcomes by as little as 3%.
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Vaewpanich J, Reuter-Rice K. Continuous electroencephalography in pediatric traumatic brain injury: Seizure characteristics and outcomes. Epilepsy Behav 2016; 62:225-30. [PMID: 27500827 PMCID: PMC5014598 DOI: 10.1016/j.yebeh.2016.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality. Secondary injury that occurs as a result of a direct impact plays a crucial role in patient prognosis. The guidelines for the management of severe TBI target treatment of secondary injury. Posttraumatic seizure, one of the secondary injury sequelae, contributes to further damage to the injured brain. Continuous electroencephalography (cEEG) helps detect both clinical and subclinical seizure, which aids early detection and prompt treatment. OBJECTIVE The aim of this study was to examine the relationship between cEEG findings in pediatric traumatic brain injury and neurocognitive/functional outcomes. METHODS This study focuses on a subgroup of a larger prospective parent study that examined children admitted to a level-1 trauma hospital. The subgroup included sixteen children admitted to the pediatric intensive care unit (PICU) who received cEEG monitoring. Characteristics included demographics, cEEG reports, and antiseizure medication. We also examined outcome scores at the time of discharge and 4-6weeks postdischarge using the Glasgow Outcome Scale - Extended Pediatrics and center-based speech pathology neurocognitive/functional evaluation scores. RESULTS Sixteen patients were included in this study. Patients with severe TBI made up the majority of those that received cEEG monitoring. Nonaccidental trauma was the most frequent TBI etiology (75%), and subdural hematoma was the most common lesion diagnosed by CT scan (75%). Fifteen patients received antiseizure medication, and levetiracetam was the medication of choice. Four patients (25%) developed seizures during PICU admission, and 3 patients had subclinical seizures that were detected by cEEG. One of these patients also had both a clinical and subclinical seizure. Nonaccidental trauma was an etiology of TBI in all patients with seizures. Characteristics of a nonreactive pattern, severe/burst suppression, and lack of sleep architecture, on cEEG, were associated with poor neurocognitive/functional outcome. CONCLUSION Continuous electroencephalography demonstrated a pattern that associated seizures and poor outcomes in patients with moderate to severe traumatic brain injury, particularly in a subgroup of patients with nonaccidental trauma. Best practice should include institution-based TBI cEEG protocols, which may detect seizure activity early and promote outcomes. Future studies should include examination of individual cEEG characteristics to help improve outcomes in pediatric TBI.
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Affiliation(s)
- Jarin Vaewpanich
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Thung Phaya Thai, Ratchathewi, Bangkok 10400, Thailand.
| | - Karin Reuter-Rice
- School of Nursing, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States; School of Medicine, Dept. of Pediatrics, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States; Duke University, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States.
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Williams RP, Banwell B, Berg RA, Dlugos DJ, Donnelly M, Ichord R, Kessler SK, Lavelle J, Massey SL, Hewlett J, Parker A, Topjian A, Abend NS. Impact of an ICU EEG monitoring pathway on timeliness of therapeutic intervention and electrographic seizure termination. Epilepsia 2016; 57:786-95. [PMID: 26949220 PMCID: PMC4862885 DOI: 10.1111/epi.13354] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We aimed to determine whether implementation of a structured multidisciplinary electroencephalography (EEG) monitoring pathway improved the timeliness of administration of antiseizure medication in response to electrographic seizures in encephalopathic critically ill children. METHODS A multidisciplinary team developed a pathway to standardize EEG monitoring and seizure management in encephalopathic critically ill children, aiming to decrease the time from electrographic seizure onset to antiseizure medication administration. Data were collected to inform the team of improvement opportunities, which were then provided by an institutional pathway, staff education, and streamlined communication. Measurements were obtained before and after pathway implementation to assess for improvement. RESULTS We collected data on 41 patients before and 21 after pathway implementation. There were no differences between the baseline and pathway groups in demographic characteristics, acute encephalopathy etiologies, or antiseizure medications utilized. The median duration [interquartile range, IQR] from seizure onset to antiseizure medication administration was shorter for patients treated with the pathway (64 min [50, 101]) compared to patients treated prior to pathway implementation (139 min [71, 189]; p = 0.0006). The median [IQR] interval from seizure onset to antiseizure medication order was shorter for the pathway group (31 min [20, 49]) than the baseline group (71 min [33, 131]; p = 0.003). The median [IQR] interval from antiseizure medication order to administration was shorter for the pathway group (30 min [19, 40]) than the baseline group (40 min [17, 68]) (p = 0.047). Seizure termination was more likely to occur following initial antiseizure medication administration in the pathway than baseline group (67% vs. 27%, p = 0.002). SIGNIFICANCE Implementation of the pathway resulted in a significant reduction in the duration between electrographic seizure onset and antiseizure medication administration, and a significant increase in the rate of electrographic seizure termination following an initial antiseizure medication. Further study is needed to determine whether these changes are associated with improved outcomes.
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Affiliation(s)
- Ryan P. Williams
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Brenda Banwell
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Robert A. Berg
- Department of Critical Care Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Dennis J. Dlugos
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | | | - Rebecca Ichord
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Sudha Kilaru Kessler
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Jane Lavelle
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Shavonne L. Massey
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Jennifer Hewlett
- Department of Pharmacy Services, The Children’s Hospital of Philadelphia
| | - Allison Parker
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Alexis Topjian
- Department of Critical Care Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Nicholas S. Abend
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Neurodiagnostics, The Children’s Hospital of Philadelphia
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Smith DM, McGinnis EL, Walleigh DJ, Abend NS. Management of Status Epilepticus in Children. J Clin Med 2016; 5:jcm5040047. [PMID: 27089373 PMCID: PMC4850470 DOI: 10.3390/jcm5040047] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/02/2016] [Accepted: 04/07/2016] [Indexed: 01/04/2023] Open
Abstract
Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children.
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Affiliation(s)
- Douglas M Smith
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Emily L McGinnis
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Diana J Walleigh
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Author Response: Concerns About Utility and Cost-Effectiveness of Continuous Critical-Care EEG. J Clin Neurophysiol 2016; 32:442-3. [PMID: 26426771 DOI: 10.1097/wnp.0000000000000220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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38
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Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol 2016; 32:87-95. [PMID: 25626778 DOI: 10.1097/wnp.0000000000000166] [Citation(s) in RCA: 382] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance. METHODS The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society developed expert consensus recommendations on the use of CCEEG in critically ill adults and children. RECOMMENDATIONS The consensus panel recommends CCEEG for diagnosis of nonconvulsive seizures, nonconvulsive status epilepticus, and other paroxysmal events, and for assessment of the efficacy of therapy for seizures and status epilepticus. The consensus panel suggests CCEEG for identification of ischemia in patients at high risk for cerebral ischemia; for assessment of level of consciousness in patients receiving intravenous sedation or pharmacologically induced coma; and for prognostication in patients after cardiac arrest. For each indication, the consensus panel describes the patient populations for which CCEEG is indicated, evidence supporting use of CCEEG, utility of video and quantitative EEG trends, suggested timing and duration of CCEEG, and suggested frequency of review and interpretation. CONCLUSION CCEEG has an important role in detection of secondary injuries such as seizures and ischemia in critically ill adults and children with altered mental status.
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Wietstock SO, Bonifacio SL, Sullivan JE, Nash KB, Glass HC. Continuous Video Electroencephalographic (EEG) Monitoring for Electrographic Seizure Diagnosis in Neonates: A Single-Center Study. J Child Neurol 2016; 31:328-32. [PMID: 26129976 PMCID: PMC4696927 DOI: 10.1177/0883073815592224] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/22/2015] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine the diagnostic yield of continuous video electroencephalographic (EEG) monitoring in critically ill neonates in the setting of a novel, university-based Neonatal Neurocritical Care Service. Patient demographic characteristics, indication for seizure monitoring, and presence of electrographic seizures were obtained by chart review. Among 595 patients cared for by the Neonatal Neurocritical Care Service, 400 (67%) received continuous video EEG. The median duration of continuous video EEG monitoring was 49 (interquartile range = 22-87) hours. Electrographic seizures were captured in 105 of 400 (26% of monitored patients) and of those, 25 of 105 (24%) had no clinical correlate. In addition, 52 of 400 subjects (13%) were monitored due to paroxysmal events concerning for seizures, but never had electrographic seizures. Continuous video EEG monitoring helped confirm or rule out ongoing seizures in more than one-third of the cases. This finding helps to support the use of continuous video EEG in critically ill neonates.
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Affiliation(s)
- S O Wietstock
- Department of Neurology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - S L Bonifacio
- Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - J E Sullivan
- Department of Neurology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - K B Nash
- Department of Neurology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - H C Glass
- Department of Neurology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
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Greiner MV, Greiner HM, Caré MM, Owens D, Shapiro R, Holland K. Adding Insult to Injury: Nonconvulsive Seizures in Abusive Head Trauma. J Child Neurol 2015; 30:1778-84. [PMID: 25900138 DOI: 10.1177/0883073815580285] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/16/2015] [Indexed: 11/17/2022]
Abstract
The primary objectives of this study were to determine the prevalence of nonconvulsive seizures and nonconvulsive status epilepticus in patients with abusive head trauma who underwent electroencephalography (EEG) monitoring and to describe predictive factors for this population. Children with a diagnosis of abusive head trauma were studied retrospectively to determine the rate of EEG monitoring, the rate of nonconvulsive seizures and nonconvulsive status epilepticus, and the associated neuroimaging findings. Over 11 years, 73 of 199 (36.8%) children with abusive head trauma had electroencephalography monitoring performed. Of these, 20 (27.4%) had nonconvulsive seizures and 3 (4.1%) had nonconvulsive status epilepticus. The presence of subarachnoid hemorrhage and cortical T2 / fluid-attenuated inversion recovery signal abnormalities were both significantly associated with the presence of nonconvulsive seizures / nonconvulsive status epilepticus. Nonconvulsive seizures are relatively common in abusive head trauma and may go unrecognized. Specific neuroimaging characteristics increase the likelihood of nonconvulsive seizures on EEG.
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Affiliation(s)
- Mary V Greiner
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Hansel M Greiner
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marguerite M Caré
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Deanna Owens
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert Shapiro
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine Holland
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Wilson CA. Continuous electroencephalogram detection of non-convulsive seizures in the pediatric intensive care unit: review of the utility and impact on management and outcomes. Transl Pediatr 2015; 4:283-9. [PMID: 26835390 PMCID: PMC4728999 DOI: 10.3978/j.issn.2224-4336.2015.10.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Non-convulsive seizures (NCS) are common among critically ill children with acute encephalopathy. Continuous electroencephalogram (CEEG) monitoring is an indispensable tool to detect NCS, which is essential to guiding management and assessing prognosis. Risk factors for NCS are highest in pediatric intensive care unit (PICU) patients with altered mental status (AMS) and a recently witnessed clinical seizure, acute changes on neuroimaging, and/or interictal abnormalities on CEEG. Screening for at least 24 hours in at risk pediatric populations is ideal, but around half of NCS may be detected within the first hour. Rapid treatment of prolonged seizures or status epilepticus is critical, as higher seizure burdens have been associated with poorer outcomes in critically ill children. This review integrates current information on critically ill children with AMS and the use of CEEGs, risk factors for NCS, duration of CEEG monitoring, and how the detection of NCS impacts management and outcomes.
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Affiliation(s)
- Carey A Wilson
- Department of Child Neurology, University of Utah School of Medicine, UT 84113, USA
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42
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Abend NS, Wagenman KL, Blake TP, Schultheis MT, Radcliffe J, Berg RA, Topjian AA, Dlugos DJ. Electrographic status epilepticus and neurobehavioral outcomes in critically ill children. Epilepsy Behav 2015; 49:238-44. [PMID: 25908325 PMCID: PMC4536172 DOI: 10.1016/j.yebeh.2015.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Electrographic seizures (ESs) and electrographic status epilepticus (ESE) are common in children with acute neurologic conditions in pediatric intensive care units (PICUs), and ESE is associated with worse functional and quality-of-life outcomes. As an exploratory study, we aimed to determine if ESE was associated with worse outcomes using more detailed neurobehavioral measures. METHODS Three hundred children with an acute neurologic condition and altered mental status underwent clinically indicated EEG monitoring and were enrolled in a prospective observational study. We obtained follow-up data from subjects who were neurodevelopmentally normal prior to PICU admission. We evaluated for associations between ESE and adaptive behavior (Adaptive Behavior Assessment System-II, ABAS-II), behavioral and emotional problems (Child Behavior Checklist, CBCL), and executive function (Behavior Rating Inventory of Executive Function, BRIEF) using linear regression analyses. A p-value of <0.05 was considered significant. RESULTS One hundred thirty-seven of 300 subjects were neurodevelopmentally normal prior to PICU admission. We obtained follow-up data from 36 subjects for the CBCL, 32 subjects for the ABAS-II, and 20 subjects for the BRIEF. The median duration from admission to follow-up was 2.6 years (IQR: 1.2-3.8). There were no differences in the acute care variables (age, sex, mental status category, intubation status, paralysis status, acute neurologic diagnosis category, seizure category, EEG background category, or short-term outcome) between subjects with and without follow-up data for any of the outcome measures. On univariate analysis, significant differences were not identified for CBCL total problem (ES coefficient: -4.1, p = 0.48; ESE coefficient: 8.9, p = 0.13) or BRIEF global executive function (ES coefficient: 2.1, p = 0.78; ESE coefficient: 14.1, p = 0.06) scores, although there were trends toward worse scores in subjects with ESE. On univariate analysis, ESs were not associated with worse scores (coefficient: -21.5, p = 0.051), while ESE (coefficient: -29.7, p = 0.013) was associated with worse ABAS-II adaptive behavioral global composite scores. On multivariate analysis, when compared to subjects with no seizures, both ESs (coefficient: -28, p=0.014) and ESE (coefficient: -36, p = 0.003) were associated with worse adaptive behavioral global composite scores. DISCUSSION Among previously neurodevelopmentally normal children with acute neurologic disorders, ESs and ESE were associated with worse adaptive behavior and trends toward worse behavioral-emotional and executive function problems. This was a small exploratory study, and the impact of ESs and ESE on these neurobehavioral measures may be clarified by subsequent larger studies. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Katherine L Wagenman
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Taylor P Blake
- Psychology Department, Drexel University, Philadelphia, PA, USA
| | | | - Jerilynn Radcliffe
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dennis J Dlugos
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abend NS, Dlugos DJ, Zhu X, Schwartz ES. Utility of CT-compatible EEG electrodes in critically ill children. Pediatr Radiol 2015; 45:714-8. [PMID: 25359434 DOI: 10.1007/s00247-014-3208-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 08/29/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Electroencephalographic monitoring is being used with increasing frequency in critically ill children who may require frequent and sometimes urgent brain CT scans. Standard metallic disk EEG electrodes commonly produce substantial imaging artifact, and they must be removed and later reapplied when CT scans are indicated. OBJECTIVE To determine whether conductive plastic electrodes caused artifact that limited CT interpretation. MATERIAL AND METHODS We describe a retrospective cohort of 13 consecutive critically ill children who underwent 17 CT scans with conductive plastic electrodes during 1 year. CT images were evaluated by a pediatric neuroradiologist for artifact presence, type and severity. RESULTS All CT scans had excellent quality images without artifact that impaired CT interpretation except for one scan in which improper wire placement resulted in artifact. CONCLUSION Conductive plastic electrodes do not cause artifact limiting CT scan interpretation and may be used in critically ill children to permit concurrent electroencephalographic monitoring and CT imaging.
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Affiliation(s)
- Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA,
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Abstract
OBJECTIVE To determine the prevalence of acute symptomatic seizures in infants with supratentorial intracranial hemorrhage, to identify potential risk factors, and to determine the effect of acute seizures on long-term morbidity and mortality. DESIGN Children less than 24 months with intracranial hemorrhage were identified from a neurocritical care database. All patients who received seizure prophylaxis beginning at admission were included in the study. Risk factors studied were gender, etiology, location of hemorrhage, seizure(s) on presentation, and the presence of parenchymal injury. Acute clinical and electrographic seizures were identified from hospital medical records. Subsequent development of late seizures was determined based on clinical information from patients' latest follow-up. SETTING AND PATIENTS Patients with idiopathic neonatal intracranial hemorrhage, premature infants, and those with prior history of seizures were excluded from analysis. Seventy-two infants met inclusion criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty percent of infants had acute symptomatic seizures. The prevalence was similar regardless of whether etiology of hemorrhage was traumatic or nontraumatic. Seizures on presentation and parenchymal injury were independent risk factors of acute seizures (p = 0.001 and p = 0.006, respectively). Younger children and women were also at higher risk (p < 0.05). Twenty percent had electrographic-only seizures, and those with parenchymal injury trended toward an increased risk (p < 0.1). Acute seizures were not predictive of mortality, but nearly twice as many patients with acute seizures developed late seizures when compared with those without. Electrographic seizures and parenchymal injury were also predictive of development of late seizures (p < 0.001 and p = 0.013, respectively). CONCLUSIONS Despite seizure prophylaxis, infants with supratentorial intracranial hemorrhage are at high risk for acute symptomatic seizures. This is regardless of the etiology of hemorrhage. Younger patients, women, patients with parenchymal injury, and patients presenting with seizure are most likely to develop acute seizures. Although the benefits of seizure prophylaxis have not been studied in this specific population, these results suggest that it is an important component of acute care following intracranial hemorrhage.
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Nonconvulsive status epilepticus complicating epstein-barr virus encephalitis in a child. Case Rep Pediatr 2014; 2014:547396. [PMID: 24744940 PMCID: PMC3972953 DOI: 10.1155/2014/547396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 02/04/2014] [Indexed: 11/24/2022] Open
Abstract
Children with acute encephalopathy show prolonged electrographic seizure activity consistent with nonconvulsive status epilepticus (NCSE). Pediatric NCSE is a heterogeneous clinical entity with poor outcome and different etiologies, including central nervous system infection, stroke, toxic-metabolic syndrome, and epileptic syndrome. We report a 4-year-old girl with seizure and behavioral changes in whom the analysis of cerebrospinal fluid by polymerase chain reaction was positive for Epstein-Barr virus. We emphasize the importance of electroencephalography (EEG), and particularly, of continuous EEG monitoring for early recognition and appropriate treatment of this condition.
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Sánchez Fernández I, Abend NS, Arndt DH, Carpenter JL, Chapman KE, Cornett KM, Dlugos DJ, Gallentine WB, Giza CC, Goldstein JL, Hahn CD, Lerner JT, Matsumoto JH, McBain K, Nash KB, Payne E, Sánchez SM, Williams K, Loddenkemper T. Electrographic seizures after convulsive status epilepticus in children and young adults: a retrospective multicenter study. J Pediatr 2014; 164:339-46.e1-2. [PMID: 24161223 PMCID: PMC3946834 DOI: 10.1016/j.jpeds.2013.09.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/22/2013] [Accepted: 09/13/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the prevalence, characteristics, and predictors of electrographic seizures after convulsive status epilepticus (CSE). STUDY DESIGN This was a multicenter retrospective study in which we describe clinical and electroencephalographic (EEG) features of children (1 month to 21 years) with CSE who underwent continuous EEG monitoring. RESULTS Ninety-eight children (53 males) with CSE (median age of 5 years) underwent subsequent continuous EEG monitoring after CSE. Electrographic seizures (with or without clinical correlate) were identified in 32 subjects (33%). Eleven subjects (34.4%) had electrographic-only seizures, 17 subjects (53.1%) had electroclinical seizures, and 4 subjects (12.5%) had an unknown clinical correlate. Of the 32 subjects with electrographic seizures, 15 subjects (46.9%) had electrographic status epilepticus. Factors associated with the occurrence of electrographic seizures after CSE were a previous diagnosis of epilepsy (P = .029) and the presence of interictal epileptiform discharges (P < .0005). The median (p25-p75) duration of stay in the pediatric intensive care unit was longer for children with electrographic seizures than for children without electrographic seizures (9.5 [3-22.5] vs 2 [2-5] days, Wilcoxon test, Z = 3.916, P = .0001). Four children (4.1%) died before leaving the hospital, and we could not identify a relationship between death and the presence or absence of electrographic seizures. CONCLUSIONS After CSE, one-third of children who underwent EEG monitoring experienced electrographic seizures, and among these, one-third experienced entirely electrographic-only seizures. A previous diagnosis of epilepsy and the presence of interictal epileptiform discharges were risk factors for electrographic seizures.
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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; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Daniel H Arndt
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Royal Oak, MI; Department of Neurology, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | | | - Kevin E Chapman
- Division of Neurology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Karen M Cornett
- Division of Pediatric Neurology, Duke University Hospital and Duke University School of Medicine, Durham, NC
| | - Dennis J Dlugos
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - William B Gallentine
- Division of Pediatric Neurology, Duke University Hospital and Duke University School of Medicine, Durham, NC
| | - Christopher C Giza
- Division of Neurology, Department of Pediatrics Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joshua L Goldstein
- Division of Neurology, Children's Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Jason T Lerner
- Division of Neurology, Department of Pediatrics Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joyce H Matsumoto
- Division of Neurology, Department of Pediatrics Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kristin McBain
- Division of Neurology, The Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Kendall B Nash
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Eric Payne
- Division of Neurology, The Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Sarah M Sánchez
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Korwyn Williams
- Department of Pediatrics, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Abend NS, Wusthoff CJ, Goldberg EM, Dlugos DJ. Electrographic seizures and status epilepticus in critically ill children and neonates with encephalopathy. Lancet Neurol 2014; 12:1170-9. [PMID: 24229615 DOI: 10.1016/s1474-4422(13)70246-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Electrographic seizures are seizures that are evident on EEG monitoring. They are common in critically ill children and neonates with acute encephalopathy. Most electrographic seizures have no associated clinical changes, and continuous EEG monitoring is necessary for identification. The effect of electrographic seizures on outcome is the focus of active investigation. Studies have shown that a high burden of electrographic seizures is associated with worsened clinical outcome after adjustment for cause and severity of brain injury, suggesting that a high burden of such seizures might independently contribute to secondary brain injury. Further research is needed to determine whether identification and management of electrographic seizures reduces secondary brain injury and improves outcome in critically ill children and neonates.
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Affiliation(s)
- Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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48
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Wagenman KL, Blake TP, Sanchez SM, Schultheis MT, Radcliffe J, Berg RA, Dlugos DJ, Topjian AA, Abend NS. Electrographic status epilepticus and long-term outcome in critically ill children. Neurology 2014; 82:396-404. [PMID: 24384638 DOI: 10.1212/wnl.0000000000000082] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Electrographic seizures (ES) and electrographic status epilepticus (ESE) are common in children in the pediatric intensive care unit (PICU) with acute neurologic conditions. We aimed to determine whether ES or ESE was associated with worse long-term outcomes. METHODS Three hundred children with an acute neurologic condition and encephalopathy underwent clinically indicated EEG monitoring and were enrolled in a prospective observational study. We aimed to obtain follow-up data from 137 subjects who were neurodevelopmentally normal before PICU admission. RESULTS Follow-up data were collected for 60 of 137 subjects (44%) at a median of 2.7 years. Subjects with and without follow-up data were similar in clinical characteristics during the PICU admission. Among subjects with follow-up data, ES occurred in 12 subjects (20%) and ESE occurred in 14 subjects (23%). Multivariable analysis indicated that ESE was associated with an increased risk of unfavorable Glasgow Outcome Scale (Extended Pediatric Version) category (odds ratio 6.36, p = 0.01) and lower Pediatric Quality of Life Inventory scores (23 points lower, p = 0.001). Among subjects without prior epilepsy diagnoses ESE was associated with an increased risk of subsequently diagnosed epilepsy (odds ratio 13.3, p = 0.002). ES were not associated with worse outcomes. CONCLUSIONS Among children with acute neurologic disorders who were reported to be neurodevelopmentally normal before PICU admission, ESE but not ES was associated with an increased risk of unfavorable global outcome, lower health-related quality of life scores, and an increased risk of subsequently diagnosed epilepsy even after adjusting for neurologic disorder category, EEG background category, and age.
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Affiliation(s)
- Katherine L Wagenman
- From the Department of Anesthesia and Critical Care Medicine (R.A.B., A.A.T.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Division of Neurology (K.L.W., S.M.S., D.J.D., N.S.A.), The Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (D.J.D., N.S.A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia; Psychology Department (T.P.B., M.T.S.), Drexel University, Philadelphia, PA; and Department of Pediatrics (J.R.), Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, PA
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A review of long-term EEG monitoring in critically ill children with hypoxic-ischemic encephalopathy, congenital heart disease, ECMO, and stroke. J Clin Neurophysiol 2013; 30:134-42. [PMID: 23545764 DOI: 10.1097/wnp.0b013e3182872af9] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Continuous EEG monitoring is being used with increasing frequency in critically ill children with hypoxic ischemic encephalopathy, congenital heart disease, stroke, and extracorporeal membrane oxygenation (ECMO). The primary indication for EEG monitoring is to identify electrographic seizures and electrographic status epilepticus, which have been associated with worse outcome in some populations. A secondary indication is to provide prognostic information. This review summarizes the available data regarding continuous EEG monitoring in critically ill children with special attention to hypoxic ischemic encephalopathy, congenital heart disease, stroke, and children undergoing ECMO.
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50
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Abstract
Traumatic brain injury is a leading cause of childhood morbidity and mortality. The use of continuous EEG monitoring in the pediatric intensive care unit setting to aid in the management of acute traumatic brain injury is becoming more common, although practice does vary between institutions. This variability is a product of the relative paucity of data, particularly as it applies to prospective studies, in evaluating the use of continuous EEG after traumatic brain injury in the pediatric population. This review will summarize the current literature involving the utility of continuous EEG monitoring in children with acute traumatic brain injury, with focus on specific indications, impact on management, and prognostic value.
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