1
|
Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
Collapse
Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
| |
Collapse
|
2
|
Hsiao CL, Chen PY, Chen IA, Lin SK. The Role of Routine Electroencephalography in the Diagnosis of Seizures in Medical Intensive Care Units. Diagnostics (Basel) 2024; 14:1111. [PMID: 38893637 PMCID: PMC11171977 DOI: 10.3390/diagnostics14111111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Seizures should be diagnosed and treated to ensure optimal health outcomes in critically ill patients admitted in the medical intensive care unit (MICU). Continuous electroencephalography is still infrequently used in the MICU. We investigated the effectiveness of routine EEG (rEEG) in detecting seizures in the MICU. A total of 560 patients admitted to the MICU between October 2018 and March 2023 and who underwent rEEG were reviewed. Seizure-related rEEG constituted 47% of all rEEG studies. Totally, 39% of the patients experienced clinical seizures during hospitalization; among them, 48% experienced the seizure, and 13% experienced their first seizure after undergoing an rEEG study. Seventy-seven percent of the patients had unfavorable short-term outcomes. Patients with cardiovascular diseases were the most likely to have the suppression/burst suppression (SBS) EEG pattern and the highest mortality rate. The rhythmic and periodic patterns (RPPs) and electrographic seizure (ESz) EEG pattern were associated with seizures within 24 h after rEEG, which was also related to unfavorable outcomes. Significant predictors of death were age > 59 years, the male gender, the presence of cardiovascular disease, a Glasgow Coma Scale score ≤ 5, and the SBS EEG pattern, with a predictive performance of 0.737 for death. rEEG can help identify patients at higher risk of seizures. We recommend repeated rEEG in patients with ESz or RPP EEG patterns to enable a more effective monitoring of seizure activities.
Collapse
Affiliation(s)
- Cheng-Lun Hsiao
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-L.H.); (P.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Pei-Ya Chen
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-L.H.); (P.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - I-An Chen
- Taiwan Center for Drug Evaluation, Taipei 11557, Taiwan;
| | - Shinn-Kuang Lin
- Stroke Center and Department of Neurology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-L.H.); (P.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| |
Collapse
|
3
|
González-Trujano ME, Urbina-Trejo E, Santos-Valencia F, Villasana-Salazar B, Carmona-Aparicio L, Martínez-Vargas D. Pharmacological and toxicological effects of Ruta chalepensis L. on experimentally induced seizures and electroencephalographic spectral power in mice. JOURNAL OF ETHNOPHARMACOLOGY 2021; 271:113866. [PMID: 33485978 DOI: 10.1016/j.jep.2021.113866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/22/2020] [Accepted: 01/18/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ruta chalepensis L. (Rutaceae) is used in traditional medicine to treat a wide variety of disorders such as rheumatism, fever, mental disorders, dropsy, neuralgia, menstrual problems, anxiety, and epilepsy. AIM OF THE STUDY To evaluate and compare the anticonvulsant properties of an aqueous extract and ethyl acetate (AcOEt) fraction of R. chalepensis on pentylenetetrazole (PTZ)-induced seizures and maximal electroshock (MES) test in mice, by analyzing behavior and electroencephalogram (EEG), as well as GABAA receptors involvement. METHODS The effect of an acute administration of different dosage of the aqueous extract (300 or 500 mg/kg) or AcOEt fraction (100, 300, 500 or 1000 mg/kg) of R. chalepensis was explored on two different models of acute seizure induction in mice, the PTZ and maximal electroshock (MES) tests. Behavioral and electrographic effects were quantified. Additionally, the possible involvement of the GABAA receptors was explored in the presence of picrotoxin (a non-competitive antagonist of the GABAA receptor). RESULTS AcOEt fraction of R. chalepensis was more efficient than aqueous extract to reduce the incidence of tonic-clonic seizures and mortality in a significant and dose-dependent manner in both the PTZ and MES tests. This anticonvulsant effect was not abolished in the presence of picrotoxin. The EEG spectral power analysis revealed that aqueous extract decreased alpha and beta power, while AcOEt fraction decreased alpha and gamma power confirming previous findings of its depressant effect in the central nervous system. It is important to mention that the highest dosage of the AcOEt (1000 mg/kg) produced a severe suppression or isoelectric EEG activity (EEG flattening), recognized as a comatose state, suggesting a neurotoxic effect at this dosage. CONCLUSION Our data reinforce that depressant and anticonvulsant effects of R. chalepensis depend in part on the presence of constituents from medium polarity. We also found that anticonvulsant effect is not mediated by GABAA receptors. In addition, cautious is emphasized when high doses of this natural product are used in traditional medicine since it might produce neurotoxic effects.
Collapse
Affiliation(s)
- M E González-Trujano
- Laboratorio de Neurofarmacología de Productos Naturales, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría "Ramón de La Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Ciudad de México, Mexico.
| | - E Urbina-Trejo
- Laboratorio de Neurofisiología Del Control y La Regulación, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría "Ramón de La Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Ciudad de México, Mexico.
| | - F Santos-Valencia
- Laboratorio de Neurofisiología Del Control y La Regulación, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría "Ramón de La Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Ciudad de México, Mexico.
| | - B Villasana-Salazar
- Laboratorio de Neurofisiología Del Control y La Regulación, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría "Ramón de La Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Ciudad de México, Mexico.
| | - L Carmona-Aparicio
- Laboratorio de Neurociencias, Instituto Nacional de Pediatría, 04530, Ciudad de México, Mexico.
| | - D Martínez-Vargas
- Laboratorio de Neurofisiología Del Control y La Regulación, Dirección de Investigaciones en Neurociencias, Instituto Nacional de Psiquiatría "Ramón de La Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Ciudad de México, Mexico.
| |
Collapse
|
4
|
Laing J, Lawn N, Perucca P, Kwan P, O'Brien TJ. Continuous EEG use and status epilepticus treatment in Australasia: a practice survey of Australian and New Zealand epileptologists. BMJ Neurol Open 2021; 2:e000102. [PMID: 33681806 PMCID: PMC7871708 DOI: 10.1136/bmjno-2020-000102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/11/2020] [Accepted: 11/22/2020] [Indexed: 11/20/2022] Open
Abstract
Objective Continuous electroencephalography (cEEG) is increasingly used to detect non-convulsive seizures in critically ill patients but is not widely practised in Australasia. Use of cEEG is also influencing the management of status epilepticus (SE), which is rapidly evolving. We aimed to survey Australian and New Zealand cEEG use and current treatment of SE Methods A web-based survey was distributed to Epilepsy Society of Australia (ESA) members, between October and November 2019. Adult and paediatric neurologists/epileptologists with ESA membership involved in clinical epilepsy care and cEEG interpretation were invited to participate. Results Thirty-five paediatric/adult epileptologists completed the survey, 51% with over 10 years of consultant experience. cEEG was always available for only 31% of respondents, with the majority having no or only ad hoc access to cEEG. Lack of funding (74%) and personnel (71%) were the most common barriers to performing cEEG. Although experience with SE was common, responses varied regarding treatment approaches for both convulsive and non-convulsive SE. Escalation to anaesthetic treatment of convulsive SE tended to occur later than international guideline recommendations. There was general agreement that formal training in cEEG and national guidelines for SE/cEEG were needed. Conclusions cEEG availability remains limited in Australia, with lack of funding and resourcing being key commonly identified barriers. Current opinions on the use of cEEG and treatment of SE vary reflecting the complexity of management and a rapidly evolving field. An Australian-based guideline for the management of SE, including the role of cEEG is recommended.
Collapse
Affiliation(s)
- Joshua Laing
- Neuroscience, Monash University, Melbourne, Victoria, Australia.,Epilepsy Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Nicholas Lawn
- WA Adult Epilepsy Service, Western Australia Health Networks, Perth, Western Australia, Australia
| | - Piero Perucca
- Alfred Health, Monash University, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Patrick Kwan
- Neuroscience, Monash University, Melbourne, Victoria, Australia.,Epilepsy Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Neuroscience, Monash University, Melbourne, Victoria, Australia.,Epilepsy Unit, Alfred Health, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Hanin A, Demeret S, Nguyen-Michel VH, Lambrecq V, Navarro V. Continuous EEG monitoring in the follow-up of convulsive status epilepticus patients: A proposal and preliminary validation of an EEG-based seizure build-up score (EaSiBUSSEs). Neurophysiol Clin 2021; 51:101-110. [PMID: 33642131 DOI: 10.1016/j.neucli.2021.01.006] [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: 10/08/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/30/2022] Open
Abstract
Continuous electroencephalography (EEG) is a major tool for monitoring patients admitted to the intensive care unit after refractory convulsive status epilepticus, following control of convulsive movements. We review the values of different EEG patterns observed in critically ill patients for prognosis and seizure risk, together with proposed criteria for non-convulsive status epilepticus diagnosis (Salzburg Criteria), the EEG scores for prognosis (Epidemiology-based Mortality score in Status Epilepticus, EMSE) and for seizure risk (2HELPS2B). These criteria and scores, based partially on continuous EEG, are not tailored to repetitively monitor the progressive build-up leading to seizure or status epilepticus recurrence. Therefore, we propose a new EEG-based seizure build-up score in status epilepticus (EaSiBUSSEs), based on the morphology and the prevalence of the EEG patterns observed in the follow-up of convulsive status epilepticus patients. It displays subscores from the least (no interictal activity) to the most associated with seizures (focal or generalized status epilepticus). We then evaluated the performance of the EaSiBUSSEs in a cohort of eleven patients who were admitted to intensive care unit for convulsive status epilepticus and who underwent continuous EEG recording. The receiver operating curve revealed good accuracy in identifying patients who would have seizures in the next 24 h, with excellent intra- and inter-rater reliability. We believe that this score is simple to perform, and suitable for repeated monitoring of EEG following refractory convulsive status epilepticus, with quantitative description of major EEG changes leading to seizures.
Collapse
Affiliation(s)
- Aurélie Hanin
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France
| | - Sophie Demeret
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France
| | - Vi-Huong Nguyen-Michel
- AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France
| | - Virginie Lambrecq
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France; AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France
| | - Vincent Navarro
- Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, F-75013, Paris, France; AP-HP, Epilepsy Unit and Clinical Neurophysiology Department (VHNM, VL, VN), Neuro-Intensive Care Unit (SD), Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Center of Reference for Rare Epilepsies, Pitié-Salpêtrière Hospital, Paris, France.
| |
Collapse
|
6
|
Westover MB, Gururangan K, Markert MS, Blond BN, Lai S, Benard S, Bickel S, Hirsch LJ, Parvizi J. Diagnostic Value of Electroencephalography with Ten Electrodes in Critically Ill Patients. Neurocrit Care 2020; 33:479-490. [PMID: 32034656 PMCID: PMC7416437 DOI: 10.1007/s12028-019-00911-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In critical care settings, electroencephalography (EEG) with reduced number of electrodes (reduced montage EEG, rm-EEG) might be a timely alternative to the conventional full montage EEG (fm-EEG). However, past studies have reported variable accuracies for detecting seizures using rm-EEG. We hypothesized that the past studies did not distinguish between differences in sensitivity from differences in classification of EEG patterns by different readers. The goal of the present study was to revisit the diagnostic value of rm-EEG when confounding issues are accounted for. METHODS We retrospectively collected 212 adult EEGs recorded at Massachusetts General Hospital and reviewed by two epileptologists with access to clinical, trending, and video information. In Phase I of the study, we re-configured the first 4 h of the EEGs in lateral circumferential montage with ten electrodes and asked new readers to interpret the EEGs without access to any other ancillary information. We compared their rating to the reading of hospital clinicians with access to ancillary information. In Phase II, we measured the accuracy of the same raters reading representative samples of the discordant EEGs in full and reduced configurations presented randomly by comparing their performance to majority consensus as the gold standard. RESULTS Of the 95 EEGs without seizures in the selected fm-EEG, readers of rm-EEG identified 92 cases (97%) as having no seizure activity. Of 117 EEGs with "seizures" identified in the selected fm-EEG, none of the cases was labeled as normal on rm-EEG. Readers of rm-EEG reported pathological activity in 100% of cases, but labeled them as seizures (N = 77), rhythmic or periodic patterns (N = 24), epileptiform spikes (N = 7), or burst suppression (N = 6). When the same raters read representative epochs of the discordant EEG cases (N = 43) in both fm-EEG and rm-EEG configurations, we found high concordance (95%) and intra-rater agreement (93%) between fm-EEG and rm-EEG diagnoses. CONCLUSIONS Reduced EEG with ten electrodes in circumferential configuration preserves key features of the traditional EEG system. Discrepancies between rm-EEG and fm-EEG as reported in some of the past studies can be in part due to methodological factors such as choice of gold standard diagnosis, asymmetric access to ancillary clinical information, and inter-rater variability rather than detection failure of rm-EEG as a result of electrode reduction per se.
Collapse
Affiliation(s)
- M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | - Saien Lai
- Kaiser Permanente Medical Center, Panorama City, CA, USA
| | - Shawna Benard
- Keck Hospital of University of Southern California, Los Angeles, CA, USA
| | - Stephan Bickel
- Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, USA
| | | | - Josef Parvizi
- Stanford University Medical Center, Stanford, CA, USA
| |
Collapse
|