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Barami K. Confounding factors impacting the Glasgow coma score: a literature review. Neurol Res 2024; 46:479-486. [PMID: 38497232 DOI: 10.1080/01616412.2024.2329860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/22/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The Glasgow coma score (GCS) is a clinical tool used to measure level of consciousness in traumatic brain injury and other settings. Despite its widespread use, there are many inaccuracies in its reporting. One source of inaccuracy is confounding factors which affect consciousness as well as each sub-score of the GCS. The purpose of this article was to create a comprehensive list of confounding factors in order to improve the accuracy of the GCS and ultimately improve decision-making. METHODS An English language literature search was conducted discussing GCS and multiple other keywords. Ultimately, 64 out of 3972 articles were included for further analysis. RESULTS A multitude of confounding factors were identified which may affect consciousness or GCS sub-scores including the eye exam, motor exam and the verbal response. CONCLUSIONS An up-to-date comprehensive list of confounding factors has been created that may be used to aide in GCS recording in hopes of improving its accuracy and utility.
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Affiliation(s)
- Kaveh Barami
- St. Francis Hospital, Trinity Health of New England, Hartford, CT, USA
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2
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Fan TH, Rosenthal ES. Physiological Monitoring in Patients with Acute Brain Injury: A Multimodal Approach. Crit Care Clin 2023; 39:221-233. [PMID: 36333033 DOI: 10.1016/j.ccc.2022.06.006] [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: 11/30/2022]
Abstract
Neurocritical care management of acute brain injury (ABI) is focused on identification, prevention, and management of secondary brain injury (SBI). Physiologic monitoring of the brain and other organ systems has a role to predict patient recovery or deterioration, guide individualized therapeutic interventions, and measure response to treatment, with the goal of improving patient outcomes. In this review, we detail how specific physiologic markers of brain injury and neuromonitoring tools are integrated and used in ABI patients to develop therapeutic approaches to prevent SBI.
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Affiliation(s)
- Tracey H Fan
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, 55 Fruit Street, Boston, MA 02493, USA
| | - Eric S Rosenthal
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Clinical Neurophysiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA.
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Bouchereau E, Sharshar T, Legouy C. Delayed awakening in neurocritical care. Rev Neurol (Paris) 2021; 178:21-33. [PMID: 34392974 DOI: 10.1016/j.neurol.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
Delayed awakening is defined as a persistent disorder of arousal or consciousness 48 to 72h after sedation interruption in critically ill patients. Delayed awakening is either a component of coma or delirium. It results in longer hospital stays and increased mortality. It is therefore a diagnostic, therapeutic and prognostic emergency. In severe brain injured patients, delayed awakening may be related to the primary neurological injury or to secondary systemic insults related to organ failure associated with intensive care. In the present review, we propose diagnostic, therapeutic and prognostic algorithms for managing delayed awaking in neuro-ICU brain injured patients.
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Affiliation(s)
- E Bouchereau
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France; INSERM U1266, FHU NeuroVasc, Institut de Psychiatrie et Neuroscience de Paris, Paris, France
| | - T Sharshar
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France; INSERM U1266, FHU NeuroVasc, Institut de Psychiatrie et Neuroscience de Paris, Paris, France.
| | - C Legouy
- G.H.U Paris Psychiatry & Neurosciences, department of Neurocritical care, Service d'Anesthésie-Réanimation Neurochirurgicale, 1, rue Cabanis, 75674 Paris Cedex 14, France
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Galovic M, Ferreira-Atuesta C, Abraira L, Döhler N, Sinka L, Brigo F, Bentes C, Zelano J, Koepp MJ. Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management. Drugs Aging 2021; 38:285-299. [PMID: 33619704 PMCID: PMC8007525 DOI: 10.1007/s40266-021-00837-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 12/14/2022]
Abstract
Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK.
| | - Carolina Ferreira-Atuesta
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Laura Abraira
- Epilepsy Unit, Department of Neurology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Nico Döhler
- Specialist Clinic for Neurorehabilitation, Kliniken Beelitz, Beelitz-Heilstätten, Germany
| | - Lucia Sinka
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Carla Bentes
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria-CHLN, Lisboa, Portugal
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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5
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Seizures and Sepsis: A Narrative Review. J Clin Med 2021; 10:jcm10051041. [PMID: 33802419 PMCID: PMC7959335 DOI: 10.3390/jcm10051041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/21/2022] Open
Abstract
Patients with sepsis-associated encephalopathy (SAE) can develop convulsive or nonconvulsive seizures. The cytokine storm and the overwhelming systemic inflammation trigger the electric circuits that promote seizures. Several neurologic symptoms, associated with this disease, range from mild consciousness impairment to coma. Focal or generalized convulsive seizures are frequent in sepsis, although nonconvulsive seizures (NCS) are often misdiagnosed and prevalent in SAE. In order to map the trigger zone in all patients that present focal or generalized seizures and also to detect NCS, EEG is indicated but continuous EEG (cEEG) is not very widespread; timing, duration, and efficacy of this tool are still unknown. The long-term risk of seizures in survivors is increased. The typical stepwise approach of seizures management begins with benzodiazepines and follows with anticonvulsants up to anesthetic drugs such as propofol or thiopental, which are able to induce burst suppression and interrupt the pathological electrical circuits. This narrative review discusses pathophysiology, clinical presentation, diagnosis and treatment of seizures in sepsis.
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Kromm J, Fiest KM, Alkhachroum A, Josephson C, Kramer A, Jette N. Structure and Outcomes of Educational Programs for Training Non-electroencephalographers in Performing and Screening Adult EEG: A Systematic Review. Neurocrit Care 2021; 35:894-912. [PMID: 33591537 DOI: 10.1007/s12028-020-01172-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To qualitatively and quantitatively summarize curricula, teaching methods, and effectiveness of educational programs for training bedside care providers (non-experts) in the performance and screening of adult electroencephalography (EEG) for nonconvulsive seizures and other patterns. METHODS PRISMA methodological standards were followed. MEDLINE, EMBASE, Cochrane, CINAHL, WOS, Scopus, and MedEdPORTAL databases were searched from inception until February 26, 2020 with no restrictions. Abstract and full-text review was completed in duplicate. Studies were included if they were original research; involved non-experts performing, troubleshooting, or screening adult EEG; and provided qualitative descriptions of curricula and teaching methods and/or quantitative assessment of non-experts (vs gold standard EEG performance by neurodiagnostic technologists or interpretation by neurophysiologists). Data were extracted in duplicate. A content analysis and a meta-narrative review were performed. RESULTS Of 2430 abstracts, 35 studies were included. Sensitivity and specificity of seizure identification varied from 38 to 100% and 65 to 100% for raw EEG; 40 to 93% and 38 to 95% for quantitative EEG, and 95 to 100% and 65 to 85% for sonified EEG, respectively. Non-expert performance of EEG resulted in statistically significant reduced delay (86 min, p < 0.0001; 196 min, p < 0.0001; 667 min, p < 0.005) in EEG completion and changes in management in approximately 40% of patients. Non-experts who were trained included physicians, nurses, neurodiagnostic technicians, and medical students. Numerous teaching methods were utilized and often combined, with instructional and hands-on training being most common. CONCLUSIONS Several different bedside providers can be educated to perform and screen adult EEG, particularly for the purpose of diagnosing nonconvulsive seizures. While further rigorous research is warranted, this review demonstrates several potential bridges by which EEG may be integrated into the care of critically ill patients.
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Affiliation(s)
- Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada. .,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ayham Alkhachroum
- Neurocritical Care Division, Miller School of Medicine, University of Miami, Miami, USA
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Room 04112, Foothills Medical Centre, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine, Mount Sinai, New York, USA
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Abstract
PURPOSE OF REVIEW Seizures and status epilepticus are very common diagnoses in the critically ill patient and are associated with significant morbidity and mortality. There is an abundance of research on the utility of antiseizure medications in this setting, but limited randomized-controlled trials to guide the selection of medications in these patients. This review examines the current guidelines and treatment strategies for status epilepticus and provides an update on newer antiseizure medications in the critical care settings. RECENT FINDINGS Time is brain applies to status epilepticus, with delays in treatment corresponding with worsened outcomes. Establishing standardized treatment protocols within a health system, including prehospital treatment, may lead to improved outcomes. Once refractory status epilepticus is established, continuous deep sedation with intravenous anesthetic agents should be effective. In cases, which prove highly refractory, novel approaches should be considered, with recent data suggesting multiple recently approved antiseizure medications, appropriate therapeutic options, as well as novel approaches to upregulate extrasynaptic γ-aminobutyric acid channels with brexanolone. SUMMARY Although there are many new treatments to consider for seizures and status epilepticus in the critically ill patient, the most important predictor of outcome may be rapid diagnosis and treatment. There are multiple new and established medications that can be considered in the treatment of these patients once status epilepticus has become refractory, and a multidrug regimen will often be necessary.
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Abstract
OBJECTIVES To pool prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, and epileptiform activity detected by different electroencephalography types in critically ills and to compare detection rates among them. DATA SOURCES MEDLINE (via PubMed) and SCOPUS (via Scopus) STUDY SELECTION:: Any type of study was eligible if studies were done in adult critically ill, applied any type of electroencephalography, and reported seizure rates. Case reports and case series were excluded. DATA EXTRACTION Data were extracted independently by two investigators. Separated pooling of prevalence of nonconvulsive seizure/nonconvulsive status epilepticus/epileptiform activity and odds ratio of detecting outcomes among different types of electroencephalography was performed using random-effect models. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and also adhered to the Meta-analyses Of Observational Studies in Epidemiology guidelines. Quality of evidence was assessed with the Newcastle-Ottawa Quality Assessment Scale for observational studies and Cochrane methods for randomized controlled trial studies. DATA SYNTHESIS A total of 78 (16,707 patients) and eight studies (4,894 patients) were eligible for pooling prevalence and odds ratios. For patients with mixed cause of admission, the pooled prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, either nonconvulsive seizure or nonconvulsive status epilepticus detected by routine electroencephalography was 3.1%, 6.2%, and 6.3%, respectively. The corresponding prevalence detected by continuous electroencephalography monitoring was 17.9%, 9.1%, and 15.6%, respectively. In addition, the corresponding prevalence was high in post convulsive status epilepticus (33.5%, 20.2%, and 32.9%), CNS infection (23.9%, 18.1%, and 23.9%), and post cardiac arrest (20.0%, 17.3%, and 22.6%). The pooled conditional log odds ratios of nonconvulsive seizure/nonconvulsive status epilepticus detected by continuous electroencephalography versus routine electroencephalography from studies with paired data 2.57 (95% CI, 1.11-5.96) and pooled odds ratios from studies with independent data was 1.57 (95% CI, 1.00-2.47). CONCLUSIONS Prevalence of seizures detected by continuous electroencephalography was significantly higher than with routine electroencephalography. Prevalence was particularly high in post convulsive status epilepticus, CNS infection, and post cardiac arrest.
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de Oliveira Manoel AL, van der Jagt M, Amin-Hanjani S, Bambakidis NC, Brophy GM, Bulsara K, Claassen J, Connolly ES, Hoffer SA, Hoh BL, Holloway RG, Kelly AG, Mayer SA, Nakaji P, Rabinstein AA, Vajkoczy P, Vergouwen MDI, Woo H, Zipfel GJ, Suarez JI. Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group. Neurocrit Care 2020; 30:36-45. [PMID: 31119687 DOI: 10.1007/s12028-019-00726-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs. METHODS This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory". RESULTS We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs. CONCLUSION Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Neuroscience Research Program in the Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Canada. .,Adult Critical Care Unit, Department of Critical Care Medicine, Hospital Paulistano - UnitedHealth Group Brazil, Rua Martiniano de Carvalho, 741, Bela Vista, São Paulo, SP, 01321-001, Brazil.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Nicholas C Bambakidis
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Richmond, VA, USA
| | - Ketan Bulsara
- Department of Neurosurgery, University of Connecticut, Farmington, CT, USA
| | | | | | - S Alan Hoffer
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charite Hospital, Universitatsmedizin, Berlin, Germany
| | - Mervyn D I Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Henry Woo
- Department of Neurosurgery and Radiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | | | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Lybeck A, Cronberg T, Borgquist O, Düring JP, Mattiasson G, Piros D, Backman S, Friberg H, Westhall E. Bedside interpretation of simplified continuous EEG after cardiac arrest. Acta Anaesthesiol Scand 2020; 64:85-92. [PMID: 31465539 DOI: 10.1111/aas.13466] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Continuous EEG-monitoring (cEEG) in the ICU is recommended to assess prognosis and detect seizures after cardiac arrest but implementation is often limited by the lack of EEG-technicians and experts. The aim of the study was to assess ICU physicians ability to perform preliminary interpretations of a simplified cEEG in the post cardiac arrest setting. METHODS Five ICU physicians received training in interpretation of simplified cEEG - total training duration 1 day. The ICU physicians then interpreted 71 simplified cEEG recordings from 37 comatose survivors of cardiac arrest. The cEEG included amplitude-integrated EEG trends and two channels with original EEG-signals. Basic EEG background patterns and presence of epileptiform discharges or seizure activity were assessed on 5-grade rank-ordered scales based on standardized EEG terminology. An EEG-expert was used as reference. RESULTS There was substantial agreement (κ 0.69) for EEG background patterns and moderate agreement (κ 0.43) for epileptiform discharges between ICU physicians and the EEG-expert. Sensitivity for detecting seizure activity by ICU physicians was limited (50%), but with high specificity (87%). CONCLUSIONS After cardiac arrest, preliminary bedside interpretations of simplified cEEGs by trained ICU physicians may allow earlier detection of clinically relevant cEEG changes, prompting changes in patient management as well as additional evaluation by an EEG-expert. This strategy requires awareness of limitations of both the simplified electrode montage and the cEEG interpretations performed by ICU physicians. cEEG evaluation by an expert should not be delayed.
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Affiliation(s)
- Anna Lybeck
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Neurology Lund Sweden
| | - Ola Borgquist
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Joachim Pascal Düring
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Gustav Mattiasson
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - David Piros
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Sofia Backman
- Department of Clinical Sciences Lund Lund UniversitySkane University HospitalClinical Neurophysiology Lund Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund Lund UniversitySkane University HospitalClinical Neurophysiology Lund Sweden
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Ruhatiya RS, Adukia SA, Manjunath RB, Maheshwarappa HM. Current Status and Recommendations in Multimodal Neuromonitoring. Indian J Crit Care Med 2020; 24:353-360. [PMID: 32728329 PMCID: PMC7358870 DOI: 10.5005/jp-journals-10071-23431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Every patient in neurocritical care evolves through two phases. Acute pathologies are addressed first. These include trauma, hemorrhagic or ischemic stroke, or neuroinfection. Soon after, the concentration shifts to identifying secondary pathologies like fever, seizures, and ischemia, which may exacerbate the brain injury. Frequent bedside examinations are not sufficient for timely detection and prevention of secondary brain injury (SBI) as per the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Multimodality monitoring (MMM) can help in tailoring treatment decisions to prevent such a brain injury. Multimodal neuromonitoring involves data-guided therapeutic interventions by employing various tools and data integration to understand brain physiology. Monitors provide real-time information on cerebral hemodynamics, oxygenation, metabolism, and electrophysiology. The monitors may be invasive/noninvasive and global/regional. We have reviewed such technologies in this write-up. Novel themes like bioinformatics, clinical research, and device development will also be discussed.
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Affiliation(s)
- Radhika S Ruhatiya
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Sachin A Adukia
- Department of Neurology, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Ramya B Manjunath
- Department of Anesthesia, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Harish M Maheshwarappa
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
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12
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Gummadavelli A, Quraishi IH, Gerrard JL. Responsive Neurostimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Continuous EEG Monitoring Predicts a Clinically Meaningful Recovery Among Adult Inpatients. J Clin Neurophysiol 2019; 36:358-364. [DOI: 10.1097/wnp.0000000000000594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abstract
PURPOSE OF REVIEW This article focuses on the multiple neuromonitoring devices that can be used to collect bedside data in the neurocritical care unit and the methodology to integrate them into a multimodality monitoring system. The article describes how to apply the collected data to appreciate the physiologic changes and develop therapeutic approaches to prevent secondary injury. RECENT FINDINGS The neurologic examination has served as the primary monitor for secondary brain injury in patients admitted to the neurocritical care unit. However, the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care concluded that frequent bedside examinations are not sufficient to detect and prevent secondary brain injury and that integration of multimodality monitoring with advanced informatics tools will most likely enhance our assessments compared to the clinical examinations alone. This article reviews the invasive and noninvasive technologies used to monitor focal and global neurophysiologic cerebral alterations. SUMMARY Multimodal monitoring is still in the early stages of development. Research is still needed to establish more advanced monitors with the bioinformatics to identify useful trends from data gathered to predict clinical outcome or prevent secondary brain injury.
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Gavaret M, Marchi A, Lefaucheur JP. Clinical neurophysiology of stroke. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:109-119. [PMID: 31307595 DOI: 10.1016/b978-0-444-64142-7.00044-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Stroke constitutes the third most common cause of death and the leading cause of acquired neurologic handicap. During ischemic stroke, very early after the onset of the focal perfusion deficit, excitotoxicity triggers a number of events that can further contribute to tissue death. Such events include peri-infarct depolarizations and spreading depolarizations (SDs) within the ischemic penumbra. SDs spread slowly through continuous gray matter at a typical velocity of 2-5mm/min. SDs exacerbate neuronal injury through prolonged ionic breakdown and SD-related hypoperfusion (spreading ischemia). Scalp EEG alone is not yet sufficient to reliably diagnose SDs. Hyperexcitability occurs in parallel, both in the acute and chronic phases of stroke. Stroke is a common cause of new-onset epileptic seizures after middle age and is the leading cause of symptomatic epilepsy in adults. The last part of this chapter is dedicated to noninvasive neurophysiologic techniques that can be used to promote stroke rehabilitation. These techniques mainly include repetitive transcranial magnetic stimulation and tDCS. These approaches are based on the concept of interhemispheric rivalry and aim at modulating the imbalance of cortical activities between both hemispheres resulting from stroke.
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Affiliation(s)
- Martine Gavaret
- INSERM UMR894, Paris Descartes University, Paris, France; Service de Neurophysiologie Clinique, Centre Hospitalier Sainte Anne, Paris, France.
| | - Angela Marchi
- Service de Neurophysiologie Clinique, Centre Hospitalier Sainte Anne, Paris, France
| | - Jean-Pascal Lefaucheur
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; EA 4391, Université Paris Est Créteil, Créteil, France
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16
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Multimodal Approach to Decision to Treat Critically Ill Patients With Periodic or Rhythmic Patterns Using an Ictal-Interictal Continuum Spectral Severity Score. J Clin Neurophysiol 2018; 35:314-324. [PMID: 29979290 DOI: 10.1097/wnp.0000000000000468] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
We propose a comprehensive review of the subject of epileptiform and potentially harmful EEG patterns that lie on the interictal continuum (IIC) to help with therapeutic decision-making and target future research. This approach to "electro-physiological SE" encompasses five dimensions of the IIC: it characterizes a periodic or rhythmic pattern, not only regarding its ictal morphology and potential harm with secondary neuronal injury, but also addresses the "metabolic footprint," clinical repercussion, and epileptogenic potential. Recent studies have attempted to determine and qualify the ictal nature and the epileptogenic potential (i.e., risk of subsequent acute seizures) of particular IIC patterns and their intrinsic EEG characteristics. Others have correlated non-convulsive seizures with cognitive outcomes beyond mortality; non-convulsive seizures and sporadic, periodic, or rhythmic discharges to encephalopathy severity; and the spectrum of periodic or rhythmic patterns to measurable secondary brain injury. Equivocal periodic or rhythmic patterns on the IIC are frequently encountered in critical care neurology where clinicians often incorporate advanced neuroimaging, metabolic neuromonitoring, and anti-seizure drug short trials, in an effort to gauge these patterns. We propose portraying the IIC with a multiaxial graph to disambiguate each of these risks. Quantification along each axis may help calibrate therapeutic urgency. An adaptable scoring system assesses which quasi-ictal EEG patterns in this spectrum might reach the tipping point toward anti-seizure drug escalation, in neurocritically ill patients.
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17
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Al-Mufti F, Lander M, Smith B, Morris NA, Nuoman R, Gupta R, Lissauer ME, Gupta G, Lee K. Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers. J Intensive Care Med 2018; 34:449-463. [PMID: 30205730 DOI: 10.1177/0885066618788022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.
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Affiliation(s)
- Fawaz Al-Mufti
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,2 Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Megan Lander
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brendan Smith
- 4 Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Nicholas A Morris
- 5 Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rolla Nuoman
- 6 Department of Neurology, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Rajan Gupta
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Matthew E Lissauer
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gaurav Gupta
- 7 Division of Neurosurgery, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kiwon Lee
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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18
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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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19
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Abstract
PURPOSE OF REVIEW Posttraumatic seizures (PTS) and posttraumatic epilepsy (PTE) are common and debilitating consequences of traumatic brain injury (TBI). Early PTS result in secondary brain injury by raising intracranial pressure and worsening cerebral edema and metabolic crisis. PTE is a localization-related epilepsy strongly associated with TBI severity, but risk factors for PTE and epileptogenesis are incompletely understood and are active areas of research. Medical management of PTS in adults and children is reviewed. Surgical options for posttraumatic drug-resistant epilepsy are also discussed. RECENT FINDINGS Continuous electroencephalography is indicated for children and adults with TBI and coma because of the high incidence of nonconvulsive seizures, periodic discharges, and associated secondary brain injury in this population. Neuroinflammation is a central component of secondary brain injury and appears to play a key role in epileptogenesis. Levetiracetam is increasingly used for seizure prophylaxis in adults and children, but variability remains. SUMMARY PTS occur commonly after TBI and are associated with secondary brain injury and worse outcomes in adults and children. Current medical and surgical management options for PTS and PTE are reviewed.
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20
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Aquino L, Kang CY, Harada MY, Ko A, Do-nguyen A, Ley EJ, Margulies DR, Alban RF. Is Routine Continuous EEG for Traumatic Brain Injury Beneficial? Am Surg 2017. [DOI: 10.1177/000313481708301232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
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Affiliation(s)
- Lia Aquino
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christopher Y. Kang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy Do-nguyen
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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21
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Bentes C, Rodrigues FB, Sousa D, Duarte GS, Franco AC, Marques R, Nzwalo H, Peralta AR, Ferro JM, Costa J. Frequency of post-stroke electroencephalographic epileptiform activity - a systematic review and meta-analysis of observational studies. Eur Stroke J 2017; 2:361-368. [PMID: 31008328 PMCID: PMC6453191 DOI: 10.1177/2396987317731004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/18/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Cerebrovascular diseases are the most frequent risk factor for epilepsy in the elderly, and epileptic phenomenon following stroke is known to worsen the prognosis. Although electroencephalography is the gold standard epilepsy biomarker, it is rarely used in post-stroke studies, and the frequency of post-stroke epileptiform activity is still uncertain. PATIENTS AND METHODS We analysed studies indexed to MEDLINE, Embase, Web of Science, PsycINFO and OpenGrey (up to March 2015), reporting post-stroke electroencephalographic epileptiform activity frequency in adults. Epileptiform activity was classified as ictal (electrographic seizures) and interictal (non-periodic spikes and sharp waves). Data selection, extraction and appraisal were done in duplicate. Random-effects meta-analysis was used to pool frequencies. RESULTS The pooled frequency of post-stroke ictal and interictal epileptiform activity was 7% (95% CI 3%-12%) and 8% (95% CI 4%-13%), respectively. The use of continuous electroencephalogram was not associated with an increased frequency of electrographic seizures (p = 0.05), nor did the management setting (Intensive Care Unit versus non- Intensive Care Unit, p = 0.31). However, studies with continuous electroencephalogram showed a higher frequency of interictal epileptiform activity (p = 0.01). DISCUSSION This study provides the best available estimates of the frequency of post-stroke electroencephalographic epileptiform activity. Due to detection bias, it was not possible to correlate clinical and electrographic seizures. CONCLUSION The frequency of ictal and interictal epileptiform activity in the electroencephalogram was comparable with previous frequency analyses of clinical seizures. The frequency of ictal epileptiform activity did not change with continuous record or clinical setting, while the frequency of interictal epileptiform activity increased with continuous record.
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Affiliation(s)
- Carla Bentes
- Department of Neurosciences and Mental
Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- EEG/Sleep Laboratory, Department of
Neurosciences and Mental Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- Faculty of Medicine, University of
Lisbon, Lisboa, Portugal
| | - Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and
Therapeutics, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
- Clinical Pharmacology Unit, Instituto de
Medicina Molecular, Lisboa, Portugal
- Huntington’s Disease Center, University
College London, UK
| | - Diana Sousa
- Department of Neurosciences and Mental
Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- Faculty of Medicine, University of
Lisbon, Lisboa, Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and
Therapeutics, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
- Clinical Pharmacology Unit, Instituto de
Medicina Molecular, Lisboa, Portugal
| | - Ana C Franco
- Department of Neurosciences and Mental
Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
| | - Raquel Marques
- Laboratory of Clinical Pharmacology and
Therapeutics, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
- Clinical Pharmacology Unit, Instituto de
Medicina Molecular, Lisboa, Portugal
| | - Hipólito Nzwalo
- Department of Biomedical Sciences and
Medicine, University of Faro, Faro, Portugal
| | - Ana R Peralta
- Department of Neurosciences and Mental
Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- EEG/Sleep Laboratory, Department of
Neurosciences and Mental Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- Faculty of Medicine, University of
Lisbon, Lisboa, Portugal
| | - José M Ferro
- Department of Neurosciences and Mental
Health (Neurology), Hospital de Santa Maria – CHLN, Lisboa, Portugal
- Faculty of Medicine, University of
Lisbon, Lisboa, Portugal
| | - João Costa
- Faculty of Medicine, University of
Lisbon, Lisboa, Portugal
- Laboratory of Clinical Pharmacology and
Therapeutics, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
- Clinical Pharmacology Unit, Instituto de
Medicina Molecular, Lisboa, Portugal
- Center for Evidence-Based Medicine,
Faculty of Medicine, University of Lisbon, Lisboa, Portugal
- Portuguese Collaborating Center of the
IberoAmerican Cochrane Network, Faculty of Medicine, University of Lisbon, Lisboa,
Portugal
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22
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Implementation of Continuous Video-Electroencephalography at a Community Hospital Enhances Care and Reduces Costs. Neurocrit Care 2017; 28:229-238. [DOI: 10.1007/s12028-017-0468-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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Bentes C, Martins H, Peralta AR, Casimiro C, Morgado C, Franco AC, Fonseca AC, Geraldes R, Canhão P, Pinho e Melo T, Paiva T, Ferro JM. Post-stroke seizures are clinically underestimated. J Neurol 2017; 264:1978-1985. [DOI: 10.1007/s00415-017-8586-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
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24
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Levetiracetam versus phenytoin for seizure prophylaxis in brain injured patients: a systematic review and meta-analysis. Int J Clin Pharm 2017; 39:998-1003. [PMID: 28780739 DOI: 10.1007/s11096-017-0507-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
Background The onset of early and/or late seizures in brain injured patients is associated with worse outcome. So far, phenytoin is the most commonly used antiepileptic drug to prevent seizures in this group of patients. Objective In the current metaanalysis, we aimed to compare the efficacy and safety of phenytoin versus levetiracetam for seizure prophylaxis in brain injured patients. Methods A systematic search was conducted in PubMed and Cochrane Library Database by 2 investigators. Four randomized controlled trials (RCTs) were included (295 patients). Data were extracted and the quality of each RCT was assessed. Results Levetiracetam was found to be more effective than phenytoin in seizure prophylaxis (OR = 0.23; CI 95% [0.09-0.56]; Q test p value = 0.18 and I2 = 38%). A trend toward less serious side effects was also found in patients treated with levetiracetam (OR = 0.27; CI 95% [0.07-1.07]; Q test p value = 0.72 and I2 = 0%). Conclusion Levetiracetam is more effective and safer than phenytoin for seizure prophylaxis in brain injured patients.
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25
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Zoerle T, Carbonara M, Zanier ER, Ortolano F, Bertani G, Magnoni S, Stocchetti N. Rethinking Neuroprotection in Severe Traumatic Brain Injury: Toward Bedside Neuroprotection. Front Neurol 2017; 8:354. [PMID: 28790967 PMCID: PMC5523726 DOI: 10.3389/fneur.2017.00354] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/06/2017] [Indexed: 12/23/2022] Open
Abstract
Neuroprotection after traumatic brain injury (TBI) is an important goal pursued strenuously in the last 30 years. The acute cerebral injury triggers a cascade of biochemical events that may worsen the integrity, function, and connectivity of the brain cells and decrease the chance of functional recovery. A number of molecules acting against this deleterious cascade have been tested in the experimental setting, often with preliminary encouraging results. Unfortunately, clinical trials using those candidate neuroprotectants molecules have consistently produced disappointing results, highlighting the necessity of improving the research standards. Despite repeated failures in pharmacological neuroprotection, TBI treatment in neurointensive care units has achieved outcome improvement. It is likely that intensive treatment has contributed to this progress offering a different kind of neuroprotection, based on a careful prevention and limitations of intracranial and systemic threats. The natural course of acute brain damage, in fact, is often complicated by additional adverse events, like the development of intracranial hypertension, brain hypoxia, or hypoperfusion. All these events may lead to additional brain damage and worsen outcome. An approach designed for early identification and prompt correction of insults may, therefore, limit brain damage and improve results.
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Affiliation(s)
- Tommaso Zoerle
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Marco Carbonara
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Elisa R Zanier
- Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milano, Italy
| | - Fabrizio Ortolano
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giulio Bertani
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Unit of Neurosurgery, Milan, Italy
| | - Sandra Magnoni
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Nino Stocchetti
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy.,Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
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26
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Dreier JP, Fabricius M, Ayata C, Sakowitz OW, William Shuttleworth C, Dohmen C, Graf R, Vajkoczy P, Helbok R, Suzuki M, Schiefecker AJ, Major S, Winkler MKL, Kang EJ, Milakara D, Oliveira-Ferreira AI, Reiffurth C, Revankar GS, Sugimoto K, Dengler NF, Hecht N, Foreman B, Feyen B, Kondziella D, Friberg CK, Piilgaard H, Rosenthal ES, Westover MB, Maslarova A, Santos E, Hertle D, Sánchez-Porras R, Jewell SL, Balança B, Platz J, Hinzman JM, Lückl J, Schoknecht K, Schöll M, Drenckhahn C, Feuerstein D, Eriksen N, Horst V, Bretz JS, Jahnke P, Scheel M, Bohner G, Rostrup E, Pakkenberg B, Heinemann U, Claassen J, Carlson AP, Kowoll CM, Lublinsky S, Chassidim Y, Shelef I, Friedman A, Brinker G, Reiner M, Kirov SA, Andrew RD, Farkas E, Güresir E, Vatter H, Chung LS, Brennan KC, Lieutaud T, Marinesco S, Maas AIR, Sahuquillo J, Dahlem MA, Richter F, Herreras O, Boutelle MG, Okonkwo DO, Bullock MR, Witte OW, Martus P, van den Maagdenberg AMJM, Ferrari MD, Dijkhuizen RM, Shutter LA, Andaluz N, Schulte AP, MacVicar B, Watanabe T, Woitzik J, Lauritzen M, Strong AJ, Hartings JA. Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group. J Cereb Blood Flow Metab 2017; 37:1595-1625. [PMID: 27317657 PMCID: PMC5435289 DOI: 10.1177/0271678x16654496] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 01/18/2023]
Abstract
Spreading depolarizations (SD) are waves of abrupt, near-complete breakdown of neuronal transmembrane ion gradients, are the largest possible pathophysiologic disruption of viable cerebral gray matter, and are a crucial mechanism of lesion development. Spreading depolarizations are increasingly recorded during multimodal neuromonitoring in neurocritical care as a causal biomarker providing a diagnostic summary measure of metabolic failure and excitotoxic injury. Focal ischemia causes spreading depolarization within minutes. Further spreading depolarizations arise for hours to days due to energy supply-demand mismatch in viable tissue. Spreading depolarizations exacerbate neuronal injury through prolonged ionic breakdown and spreading depolarization-related hypoperfusion (spreading ischemia). Local duration of the depolarization indicates local tissue energy status and risk of injury. Regional electrocorticographic monitoring affords even remote detection of injury because spreading depolarizations propagate widely from ischemic or metabolically stressed zones; characteristic patterns, including temporal clusters of spreading depolarizations and persistent depression of spontaneous cortical activity, can be recognized and quantified. Here, we describe the experimental basis for interpreting these patterns and illustrate their translation to human disease. We further provide consensus recommendations for electrocorticographic methods to record, classify, and score spreading depolarizations and associated spreading depressions. These methods offer distinct advantages over other neuromonitoring modalities and allow for future refinement through less invasive and more automated approaches.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, and Stroke Service and Neuroscience Intensive Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Klinikum Ludwigsburg, Ludwigsburg, Germany
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - C William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Rudolf Graf
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Peter Vajkoczy
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Alois J Schiefecker
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Maren KL Winkler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Denny Milakara
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Ana I Oliveira-Ferreira
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Gajanan S Revankar
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Nora F Dengler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, Neurocritical Care Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bart Feyen
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | | | | | - Henning Piilgaard
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Maslarova
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - Daniel Hertle
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | | | - Sharon L Jewell
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Baptiste Balança
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Jason M Hinzman
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janos Lückl
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Karl Schoknecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Schöll
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christoph Drenckhahn
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Delphine Feuerstein
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Nina Eriksen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Julia S Bretz
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Paul Jahnke
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Egill Rostrup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Bente Pakkenberg
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Uwe Heinemann
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Jan Claassen
- Neurocritical Care, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christina M Kowoll
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Svetlana Lublinsky
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoash Chassidim
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilan Shelef
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alon Friedman
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Michael Reiner
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Sergei A Kirov
- Department of Neurosurgery and Brain and Behavior Discovery Institute, Medical College of Georgia, Augusta, GA, USA
| | - R David Andrew
- Department of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
| | - Eszter Farkas
- Department of Medical Physics and Informatics, Faculty of Medicine, and Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Lee S Chung
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - KC Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Thomas Lieutaud
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Stephane Marinesco
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- AniRA-Neurochem Technological Platform, Lyon, France
| | - Andrew IR Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Juan Sahuquillo
- Department of Neurosurgery, Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Frank Richter
- Institute of Physiology I/Neurophysiology, Friedrich Schiller University Jena, Jena, Germany
| | - Oscar Herreras
- Department of Systems Neuroscience, Cajal Institute-CSIC, Madrid, Spain
| | | | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Ross Bullock
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Arn MJM van den Maagdenberg
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rick M Dijkhuizen
- Center for Image Sciences, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lori A Shutter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - André P Schulte
- Department of Spinal Surgery, St. Franziskus Hospital Cologne, Cologne, Germany
| | - Brian MacVicar
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Lauritzen
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience and Pharmacology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Anthony J Strong
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
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Bentes C, Martins H, Peralta AR, Morgado C, Casimiro C, Franco AC, Fonseca AC, Geraldes R, Canhão P, Pinho e Melo T, Paiva T, Ferro JM. Epileptic manifestations in stroke patients treated with intravenous alteplase. Eur J Neurol 2017; 24:755-761. [DOI: 10.1111/ene.13292] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 03/06/2017] [Indexed: 01/19/2023]
Affiliation(s)
- C. Bentes
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - H. Martins
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - A. R. Peralta
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - C. Morgado
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - C. Casimiro
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - A. C. Franco
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - A. C. Fonseca
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - R. Geraldes
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - P. Canhão
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - T. Pinho e Melo
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - T. Paiva
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
| | - J. M. Ferro
- Department of Neurosciences and Mental Health (Neurology); Hospital de Santa Maria-CHLN; Lisboa Portugal
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Abstract
Neurologic complications in polytrauma can be classified by etiology and clinical manifestations: neurovascular, delirium, and spinal or neuromuscular problems. Neurovascular complications include ischemic strokes, intracranial hemorrhage, or the development of traumatic arteriovenous fistulae. Delirium and encephalopathy have a reported incidence of 67-92% in mechanically ventilated polytrauma patients. Causes include sedation, analgesia/pain, medications, sleep deprivation, postoperative state, toxic ingestions, withdrawal syndromes, organ system dysfunction, electrolyte/metabolic abnormalities, and infections. Rapid identification and treatment of the underlying cause are imperative. Benzodiazepines increase the risk of delirium, and alternative agents are preferred sedatives. Pharmacologic treatment of agitated delirium can be achieved with antipsychotics. Nonconvulsive seizures and status epilepticus are not uncommon in surgical/trauma intensive care unit (ICU) patients, require electroencephalography for diagnosis, and need timely management. Spinal cord ischemia is a known complication in patients with traumatic aortic dissections or blunt aortic injury requiring surgery. Thoracic endovascular aortic repair has reduced the paralysis rate. Neuromuscular complications include nerve and plexus injuries, and ICU-acquired weakness. In polytrauma, the neurologic examination is often confounded by pain, sedation, mechanical ventilation, and distracting injuries. Regular sedation pauses for examination and maintaining a high index of suspicion for neurologic complications are warranted, particularly because early diagnosis and management can improve outcomes.
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Abstract
Posttraumatic seizures are a common complication of traumatic brain injury. Posttraumatic epilepsy accounts for 20% of symptomatic epilepsy in the general population and 5% of all epilepsy. Early posttraumatic seizures occur in more than 20% of patients in the intensive care unit and are associated with secondary brain injury and worse patient outcomes. Most posttraumatic seizures are nonconvulsive and therefore continuous electroencephalography monitoring should be the standard of care for patients with moderate or severe brain injury. The literature shows that posttraumatic seizures result in secondary brain injury caused by increased intracranial pressure, cerebral edema and metabolic crisis.
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30
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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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Abstract
Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.
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Reis C, Akyol O, Araujo C, Huang L, Enkhjargal B, Malaguit J, Gospodarev V, Zhang JH. Pathophysiology and the Monitoring Methods for Cardiac Arrest Associated Brain Injury. Int J Mol Sci 2017; 18:ijms18010129. [PMID: 28085069 PMCID: PMC5297763 DOI: 10.3390/ijms18010129] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/31/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest (CA) is a well-known cause of global brain ischemia. After CA and subsequent loss of consciousness, oxygen tension starts to decline and leads to a series of cellular changes that will lead to cellular death, if not reversed immediately, with brain edema as a result. The electroencephalographic activity starts to change as well. Although increased intracranial pressure (ICP) is not a direct result of cardiac arrest, it can still occur due to hypoxic-ischemic encephalopathy induced changes in brain tissue, and is a measure of brain edema after CA and ischemic brain injury. In this review, we will discuss the pathophysiology of brain edema after CA, some available techniques, and methods to monitor brain oxygen, electroencephalography (EEG), ICP (intracranial pressure), and microdialysis on its measurement of cerebral metabolism and its usefulness both in clinical practice and possible basic science research in development. With this review, we hope to gain knowledge of the more personalized information about patient status and specifics of their brain injury, and thus facilitating the physicians’ decision making in terms of which treatments to pursue.
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Affiliation(s)
- Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Camila Araujo
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Lei Huang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Budbazar Enkhjargal
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Jay Malaguit
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Vadim Gospodarev
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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33
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Abstract
Neurocritical care has two main objectives. Initially, the emphasis is on treatment of patients with acute damage to the central nervous system whether through infection, trauma, or hemorrhagic or ischemic stroke. Thereafter, attention shifts to the identification of secondary processes that may lead to further brain injury, including fever, seizures, and ischemia, among others. Multimodal monitoring is the concept of using various tools and data integration to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. This chapter will review the use of electroencephalography, intracranial pressure monitoring, brain tissue oxygenation, cerebral microdialysis and neurochemistry, near-infrared spectroscopy, and transcranial Doppler sonography as they relate to neuromonitoring in the critically ill. The concepts and design of each monitor, in addition to the patient population that may most benefit from each modality, will be discussed, along with the various tools that can be used together to guide individualized patient treatment options. Major clinical trials, observational studies, and their effect on clinical outcomes will be reviewed. The future of multimodal monitoring in the field of bioinformatics, clinical research, and device development will conclude the chapter.
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Affiliation(s)
- G Korbakis
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - P M Vespa
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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35
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Mikell CB, Dyster TG, Claassen J. Invasive seizure monitoring in the critically-Ill brain injury patient: Current practices and a review of the literature. Seizure 2016; 41:201-5. [PMID: 27364336 PMCID: PMC5505252 DOI: 10.1016/j.seizure.2016.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 05/27/2016] [Indexed: 01/17/2023] Open
Abstract
Seizures commonly occur in a variety of serious neurological illnesses, and lead to additional morbidity and worsened outcomes. Recently, it has become clear that not all seizures in the acute brain injury setting are evident on scalp EEG. To address this, we have developed a protocol for depth electrode placement in the neuro-intensive care unit for patients in whom the clinical suspicion of occult seizures is high. In the current manuscript, we review the literature on depth EEG monitoring for ictal events in critically-ill, unconscious patients, focusing on the incidence of seizures not detected with scalp EEG in various conditions. We critically discuss evidence in support of and against treating these events that are only detectable on depth recordings. We describe additional specific scenarios in which depth EEG recordings may be helpful, including for the detection of delayed cerebral ischemia following subarachnoid hemorrhage. We then describe current techniques for bedside electrode placement. Finally, we outline potential avenues for future investigations, including the use of depth electrodes to describe circuit abnormalities in acute brain injury.
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Affiliation(s)
- Charles B Mikell
- Functional and Cognitive Neurophysiology Lab, Columbia University Medical Center, Department of Neurological Surgery, New York Presbyterian Hospital, New York, NY, USA
| | - Timothy G Dyster
- Functional and Cognitive Neurophysiology Lab, Columbia University Medical Center, Department of Neurological Surgery, New York Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Columbia University Medical Center, Department of Neurology, Division of Critical Care and Hospitalist Neurology, New York Presbyterian Hospital, New York, NY, USA.
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Weitzel LR, Sampath D, Shimizu K, White AM, Herson PS, Raol YH. EEG power as a biomarker to predict the outcome after cardiac arrest and cardiopulmonary resuscitation induced global ischemia. Life Sci 2016; 165:21-25. [PMID: 27640888 DOI: 10.1016/j.lfs.2016.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 10/21/2022]
Abstract
AIMS Cardiac arrest (CA) is a major cause of mortality and survivors often develop neurologic deficits. The objective of this study was to determine the effect of CA and cardiopulmonary resuscitation (CPR) in mice on the EEG and neurologic outcomes, and identify biomarkers that can prognosticate poor outcomes. MAIN METHODS Video-EEG records were obtained at various periods following CA-CPR and examined manually to determine the presence of spikes and sharp-waves, and seizures. EEG power was calculated using a fast Fourier transform (FFT) algorithm. KEY FINDINGS Fifty percent mice died within 72h following CA and successful CPR. Universal suppression of the background EEG was observed in all mice following CA-CPR, however, a more severe and sustained reduction in EEG power occurred in the mice that did not survive beyond 72h than those that survived until sacrificed. Spikes and sharp wave activity appeared in the cortex and hippocampus of all mice, but only one out of eight mice developed a purely electrographic seizure in the acute period after CA-CPR. Interestingly, none of the mice that died experienced any acute seizures. At 10days after the CA-CPR, 25% of the mice developed spontaneous convulsive and nonconvulsive seizures that remained restricted to the hippocampus. The frequency of nonconvulsive seizures was higher than that of convulsive seizures. SIGNIFICANCE A strong association between changes in EEG power and mortality following CA-CPR were observed in our study. Therefore, we suggest that the EEG power can be used to prognosticate mortality following CA-CPR induced global ischemia.
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Affiliation(s)
- Lindsay-Rae Weitzel
- Department of Anesthesiology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Dayalan Sampath
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kaori Shimizu
- Department of Anesthesiology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Andrew M White
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Paco S Herson
- Department of Anesthesiology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pharmacology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, School of Medicine, Translational Epilepsy Research Program, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA.
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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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38
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Carron SF, Alwis DS, Rajan R. Traumatic Brain Injury and Neuronal Functionality Changes in Sensory Cortex. Front Syst Neurosci 2016; 10:47. [PMID: 27313514 PMCID: PMC4889613 DOI: 10.3389/fnsys.2016.00047] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 05/19/2016] [Indexed: 01/21/2023] Open
Abstract
Traumatic brain injury (TBI), caused by direct blows to the head or inertial forces during relative head-brain movement, can result in long-lasting cognitive and motor deficits which can be particularly consequential when they occur in young people with a long life ahead. Much is known of the molecular and anatomical changes produced in TBI but much less is known of the consequences of these changes to neuronal functionality, especially in the cortex. Given that much of our interior and exterior lives are dependent on responsiveness to information from and about the world around us, we have hypothesized that a significant contributor to the cognitive and motor deficits seen after TBI could be changes in sensory processing. To explore this hypothesis, and to develop a model test system of the changes in neuronal functionality caused by TBI, we have examined neuronal encoding of simple and complex sensory input in the rat’s exploratory and discriminative tactile system, the large face macrovibrissae, which feeds to the so-called “barrel cortex” of somatosensory cortex. In this review we describe the short-term and long-term changes in the barrel cortex encoding of whisker motion modeling naturalistic whisker movement undertaken by rats engaged in a variety of tasks. We demonstrate that the most common form of TBI results in persistent neuronal hyperexcitation specifically in the upper cortical layers, likely due to changes in inhibition. We describe the types of cortical inhibitory neurons and their roles and how selective effects on some of these could produce the particular forms of neuronal encoding changes described in TBI, and then generalize to compare the effects on inhibition seen in other forms of brain injury. From these findings we make specific predictions as to how non-invasive extra-cranial electrophysiology can be used to provide the high-precision information needed to monitor and understand the temporal evolution of changes in neuronal functionality in humans suffering TBI. Such detailed understanding of the specific changes in an individual patient’s cortex can allow for treatment to be tailored to the neuronal changes in that particular patient’s brain in TBI, a precision that is currently unavailable with any technique.
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Affiliation(s)
- Simone F Carron
- Neuroscience Research Program, Biomedicine Discovery Institute, Department of Physiology, Monash University Monash, VIC, Australia
| | - Dasuni S Alwis
- Neuroscience Research Program, Biomedicine Discovery Institute, Department of Physiology, Monash University Monash, VIC, Australia
| | - Ramesh Rajan
- Neuroscience Research Program, Biomedicine Discovery Institute, Department of Physiology, Monash UniversityMonash, VIC, Australia; Ear Sciences Institute of AustraliaPerth, WA, Australia
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Abstract
The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.
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Affiliation(s)
- David Roh
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
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40
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Löscher W, Hirsch LJ, Schmidt D. The enigma of the latent period in the development of symptomatic acquired epilepsy - Traditional view versus new concepts. Epilepsy Behav 2015; 52:78-92. [PMID: 26409135 DOI: 10.1016/j.yebeh.2015.08.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/30/2015] [Indexed: 01/21/2023]
Abstract
A widely accepted hypothesis holds that there is a seizure-free, pre-epileptic state, termed the "latent period", between a brain insult, such as traumatic brain injury or stroke, and the onset of symptomatic epilepsy, during which a cascade of structural, molecular, and functional alterations gradually mediates the process of epileptogenesis. This review, based on recent data from both animal models and patients with different types of brain injury, proposes that epileptogenesis and often subclinical epilepsy can start immediately after brain injury without any appreciable latent period. Even though the latent period has traditionally been the cornerstone concept representing epileptogenesis, we suggest that the evidence for the existence of a latent period is spotty both for animal models and human epilepsy. Knowing whether a latent period exists or not is important for our understanding of epileptogenesis and for the discovery and the trial design of antiepileptogenic agents. The development of antiepileptogenic treatments to prevent epilepsy in patients at risk from a brain insult is a major unmet clinical need.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
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Finnigan S, Wong A, Read S. Defining abnormal slow EEG activity in acute ischaemic stroke: Delta/alpha ratio as an optimal QEEG index. Clin Neurophysiol 2015; 127:1452-1459. [PMID: 26251106 DOI: 10.1016/j.clinph.2015.07.014] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/24/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Quantitative electroencephalographic (QEEG) indices sensitive to abnormal slow (relative to faster) activity power seem uniquely informative for clinical management of ischaemic stroke (IS), including around acute reperfusion therapies. However these have not been compared between IS and control samples. The primary objective was to identify the QEEG slowing index and threshold value which can most accurately discriminate between IS patients and controls. METHODS The samples comprised 28 controls (mean age: 70.4; range: 56-84) and 18 patients (mean age: 69.3; range: 51-86). Seven indices were analysed: relative bandpower (delta, theta, alpha, beta), delta/alpha power ratio (DAR), (delta+theta)/(alpha+beta) ratio (DTABR) and QSLOWING. The accuracies of each index for classifying participants (IS or control) were analysed using receiver operating characteristic (ROC) techniques. RESULTS All indices differed significantly between the samples (p<.001). DAR alone exhibited optimal classifier accuracy, with a threshold of 3.7 demonstrating 100% sensitivity and 100% specificity for discriminating between radiologically-confirmed, acute IS or control. DTABR and relative delta were the next most accurate classifiers. CONCLUSIONS DAR of 3.7 demonstrated maximal accuracy for classifying all 46 participants as acute IS or control. SIGNIFICANCE DAR assessment may inform clinical management of IS and perhaps other neurocritical patients.
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Affiliation(s)
- Simon Finnigan
- UQ Centre for Clinical Research, University of Queensland, Brisbane, Australia; Centre for Allied Health Research, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Queensland, Australia.
| | - Andrew Wong
- School of Medicine, University of Queensland, Brisbane, Australia; Acute Stroke Unit, Neurology Department, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Queensland, Australia
| | - Stephen Read
- School of Medicine, University of Queensland, Brisbane, Australia; Acute Stroke Unit, Neurology Department, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Queensland, Australia
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