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Veciana de Las Heras M, Sala-Padro J, Pedro-Perez J, García-Parra B, Hernández-Pérez G, Falip M. Utility of Quantitative EEG in Neurological Emergencies and ICU Clinical Practice. Brain Sci 2024; 14:939. [PMID: 39335433 PMCID: PMC11430096 DOI: 10.3390/brainsci14090939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/22/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
The electroencephalogram (EEG) is a cornerstone tool for the diagnosis, management, and prognosis of selected patient populations. EEGs offer significant advantages such as high temporal resolution, real-time cortical function assessment, and bedside usability. The quantitative EEG (qEEG) added the possibility of long recordings being processed in a compressive manner, making EEG revision more efficient for experienced users, and more friendly for new ones. Recent advancements in commercially available software, such as Persyst, have significantly expanded and facilitated the use of qEEGs, marking the beginning of a new era in its application. As a result, there has been a notable increase in the practical, real-world utilization of qEEGs in recent years. This paper aims to provide an overview of the current applications of qEEGs in daily neurological emergencies and ICU practice, and some elementary principles of qEEGs using Persyst software in clinical settings. This article illustrates basic qEEG patterns encountered in critical care and adopts the new terminology proposed for spectrogram reporting.
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Affiliation(s)
- Misericordia Veciana de Las Heras
- Neurology Service, Neurophysiology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jacint Sala-Padro
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Pedro-Perez
- Neurology Service, Neurophysiology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Beliu García-Parra
- Neurology Service, Neurophysiology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Hernández-Pérez
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Merce Falip
- Neurology Service, Epilepsy Unit, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
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Misirocchi F, Mutti C, Hirsch LJ, Parrino L, Florindo I. Cyclic Alternating EEG Patterns: From Sleep to Encephalopathy. J Clin Neurophysiol 2024; 41:485-494. [PMID: 39186585 DOI: 10.1097/wnp.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
SUMMARY In the 2021 version of the Standardized Critical Care EEG Terminology, the American Clinical Neurophysiology Society introduced new definitions, including for the cyclic alternating pattern of encephalopathy (CAPE). CAPE refers to changes in background EEG activity, with two patterns alternating spontaneously in a regular manner. CAPE shares remarkable similarities with the cyclic alternating pattern, a natural EEG phenomenon occurring in normal non-rapid eye movement sleep, considered the main electrophysiological biomarker of sleep instability. This review explores similarities and differences between cyclic alternating pattern and CAPE and, leveraging the existing expertise on cyclic alternating pattern, aims to extend knowledge on CAPE. A standardized assessment of CAPE features is key to ascertain its prevalence and clinical significance among critically ill patients and to encompass the impact of confounding factors such as anesthetic and sedative agents. Although the preservation of non-rapid eye movement sleep-related elements has a well-known prognostic value in the critical care setting, the clinical importance of cyclic oscillating patterns and the prognostic significance of CAPE remain to be elucidated.
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Affiliation(s)
- Francesco Misirocchi
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Carlotta Mutti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of General and Specialized Medicine, Unit of Neurology, University Hospital of Parma, Parma, Italy; and
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Liborio Parrino
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of General and Specialized Medicine, Unit of Neurology, University Hospital of Parma, Parma, Italy; and
| | - Irene Florindo
- Department of General and Specialized Medicine, Unit of Neurology, University Hospital of Parma, Parma, Italy; and
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Busl KM, Fong MWK, Newcomer Z, Patel M, Cohen SA, Jadav R, Smith CN, Mitropanopoulos S, Bruzzone M, Hella M, Eisenschenk S, Robinson CP, Roth WH, Ameli PA, Babi MA, Pizzi MA, Gilmore EJ, Hirsch LJ, Maciel CB. Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures. Neurocrit Care 2022; 37:140-148. [PMID: 35217998 DOI: 10.1007/s12028-022-01459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.
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Affiliation(s)
- Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael W K Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mitesh Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christine N Smith
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Maria Bruzzone
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher P Robinson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - William H Roth
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pouya Alexander Ameli
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc-Alain Babi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael A Pizzi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA. .,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA. .,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. .,Department of Neurology, University of Utah, Salt Lake City, UT, 81432, USA. .,Neurocritical Care, McKnight Brain Institute, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA.
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Pinto LF, Oliveira JPSD, Midon AM. Status epilepticus: review on diagnosis, monitoring and treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:193-203. [PMID: 35976303 PMCID: PMC9491413 DOI: 10.1590/0004-282x-anp-2022-s113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.
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Affiliation(s)
- Lecio Figueira Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Epilepsia, São Paulo SP, Brazil
| | | | - Aston Marques Midon
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
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Kajikawa S, Matsuhashi M, Kobayashi K, Hitomi T, Daifu-Kobayashi M, Kobayashi T, Yamao Y, Kikuchi T, Yoshida K, Kunieda T, Matsumoto R, Kakita A, Namiki T, Tsuda I, Miyamoto S, Takahashi R, Ikeda A. Two types of clinical ictal direct current shifts in invasive EEG of intractable focal epilepsy identified by waveform cluster analysis. Clin Neurophysiol 2022; 137:113-121. [PMID: 35305495 DOI: 10.1016/j.clinph.2022.02.021] [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: 10/12/2021] [Revised: 02/07/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine clinically ictal direct current (DC) shifts that can be identified by a time constant (TC) of 2 s and to delineate different types of DC shifts by different attenuation patterns between TC of 10 s and 2 s. METHODS Twenty-one patients who underwent subdural electrode implantation for epilepsy surgery were investigated. For habitual seizures, we compared (1) the peak amplitude and (2) peak latency of the earliest ictal DC shifts between TC of 10 s and 2 s. Cluster and logistic regression analyses were performed based on the attenuation rate of amplitude and peak latency with TC 10 s. RESULTS Ictal DC shifts in 120 seizures were analyzed; 89.1% of which were appropriately depicted even by a TC of 2 s. Cluster and logistic regression analyses revealed two types of ictal DC shift. Namely, a rapid development pattern was defined as the ictal DC shifts with a shorter peak latency and they also showed smaller attenuation rate of amplitude (73/120 seizures). Slow development pattern was defined as the ictal DC shifts with crosscurrent of a rapid development pattern, i.e., a longer peak latency and larger attenuation rate of amplitude (47/120 seizures). Focal cortical dysplasia (FCD) 1A tended to show a rapid development pattern (22/29 seizures) and FCD2A tended to show a slow development pattern (13 /18 seizures), indicating there might be some correlations between two types of ictal DC shift and certain pathologies. CONCLUSIONS Ictal DC shifts, especially rapid development pattern, can be recorded and identified by the AC amplifiers of TC of 2 s which is widely used in many institutes compared to that of TC of 10 s. Two types of ictal DC shifts were identified with possibility of corresponding pathology. SIGNIFICANCE Ictal DC shifts can be distinguished by their attenuation patterns.
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Affiliation(s)
- Shunsuke Kajikawa
- Department of Neurology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Masao Matsuhashi
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Katsuya Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Takefumi Hitomi
- Department of Clinical Laboratory, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Masako Daifu-Kobayashi
- Department of Neurology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Tamaki Kobayashi
- Department of Neurosurgery, Otsu City Hospital, 2 Motomiya, Otsu-shi, Shiga 520-0804, Japan; Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Kazumichi Yoshida
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Takeharu Kunieda
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan; Department of Neurosurgery, Ehime University Graduate School of Medicine, 454 Shitsukawa, Touon-shi, Ehime 791-0295, Japan.
| | - Riki Matsumoto
- Department of Neurology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan; Division of Neurology, Kobe University Graduate School of Medicine, 7 Kusunoki-cho, Chuou-ku, Kobe-shi, Hyougo 650-0017, Japan.
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, 757 Asahi-cho 1, Chuou-ku, Niigata-shi, Niigata 951-8585, Japan.
| | - Takao Namiki
- Department of Mathematics, Faculty of Science, Hokkaido University, 8 West, 10 North, Kita-ku, Sapporo-shi, Hokkaido 060-0810, Japan.
| | - Ichiro Tsuda
- Chubu University Academy of Emerging Sciences, Chubu University, 1200 Matsumoto-cho, Kasugai-shi, Aichi 487-8501, Japan.
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto-shi, Kyoto 606-8507, Japan.
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Neshige S, Katsumata R, Tomohisa N, Aoki S, Maruyama H. Screening for non-convulsive status epilepticus with density spectrum array in critical care EEG. QJM 2022; 114:893-894. [PMID: 34597397 DOI: 10.1093/qjmed/hcab258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shuichiro Neshige
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan and Epilepsy center, Hiroshima University Hospital, Hiroshima, Japan
| | - Riho Katsumata
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan and Epilepsy center, Hiroshima University Hospital, Hiroshima, Japan
| | - Nezu Tomohisa
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan and Epilepsy center, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan and Epilepsy center, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan and Epilepsy center, Hiroshima University Hospital, Hiroshima, Japan
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima
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Zorlu MM, Chuang DT, Buyukozkan M, Aydemir S, Zarnegar R. Prognostic Significance of Cyclic Seizures in Status Epilepticus. J Clin Neurophysiol 2021; 38:516-524. [PMID: 32398513 DOI: 10.1097/wnp.0000000000000714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Status epilepticus (SE) is a commonly encountered neurologic condition associated with high mortality rates. Cyclic seizures (CS) are a common form of SE, but its prognostic significance has not been well established. In this retrospective study, the mortality of cyclic versus noncyclic forms (NCSs) of SE are compared. METHODS A total of 271 patients were identified as having seizures or SE on EEG reports, of which 65 patients were confirmed as having SE. Based on EEG characteristics, the patients were then classified as cyclic or noncyclic patterns. Cyclic seizures were defined as recurrent seizures occurring at nearly regular and uniform intervals. Noncyclic form included all other patterns of SE. Pertinent clinical data were collected and reviewed for each case. RESULTS Of the 65 patients with SE, 25 patients had CS and 40 patients had NCS. Patients with CS showed a lower rate of in-hospital mortality although not statistically significant (P = 0.19). When looking at patients younger than 75 years, the CS group had significantly lower in-hospital mortality rate (P = 0.007). CONCLUSIONS The findings of this study suggest that CS may have a more favorable outcome compared with NCS in patients younger than 75 years. This study is also the first to report the rate of CS among all cases of confirmed SE (38%). Future studies with a larger sample size are needed to further evaluate the difference in outcome between CS and NCS.
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Affiliation(s)
- Musab M Zorlu
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
- Department of Neurology, University of Connecticut Health Center, Farmington, Connecticut, U.S.A .; and
| | - David T Chuang
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
| | - Mustafa Buyukozkan
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, New York, U.S.A
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
| | - Reza Zarnegar
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Periodic electroclinical seizures following an ischemic stroke revealed by continuous-EEG. Epilepsy Behav Rep 2021; 15:100428. [PMID: 33665600 PMCID: PMC7905351 DOI: 10.1016/j.ebr.2021.100428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 11/20/2022] Open
Abstract
Background Periodic EEG patterns are mostly associated with critical illnesses and acute disruptions of the central nervous system. Periodic or cyclic seizures are extremely rare phenomena, most of which are nonconvulsive, only reported in critically ill patients. Here we report a patient with periodic focal impaired awareness seizures following a minor stroke and address possible pathophysiological mechanisms. Case A 49 years old male patient presented with periodic seizures, associated with an acute stroke in the left occipital and parietal regions. These focal seizures, recorded during long-term video-EEG monitoring in the scalp EEG, appeared every 9-11 min, and responded to iv valproic acid treatment but not to iv treatments of diazepam, phenytoin, and levetiracetam. Discussion We believe that the blood-brain barrier disruption due to stroke, in conjunction with hyperglycemia and antiphospholipid antibodies have led to an imbalance of the surrounding tissue and sustained hyperexcitability to a point of pacemaker potentials. It is tempting to speculate that repetitive cycles of cortical spreading depression due to tissue injury have aided the periodicity of the seizures. Conclusion Continuous EEG monitoring is crucial, not only to diagnose and appropriately treat accompanying subtle seizures but also to further understand the underlying intriguing pathophysiological processes like periodicity.
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10
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Hammer D, Scheuer M, Fong-Isariyawongse J. Pearls & Oy-sters: Cyclic Seizures and Heart Rate Variability. Neurology 2020; 96:e1694-e1696. [PMID: 33277425 DOI: 10.1212/wnl.0000000000011317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Hammer
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA
| | - Mark Scheuer
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA
| | - Joanna Fong-Isariyawongse
- From the Department of Neurology (D.H., J.F.-I.), University of Pittsburgh Comprehensive Epilepsy Center (UPCEC), University of Pittsburgh Medical Center, PA; and Persyst Development Corporation (M.S.), Solana Beach, CA.
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11
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Murai T, Hitomi T, Matsuhashi M, Matsumoto R, Kawamura Y, Kanda M, Takahashi R, Ikeda A. Scalp EEG Could Record Both Ictal Direct Current Shift and High-Frequency Oscillation Together Even With a Time Constant of 2 Seconds. J Clin Neurophysiol 2020; 37:191-194. [DOI: 10.1097/wnp.0000000000000670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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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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Joshi RB, Duckrow RB, Goncharova II, Gerrard JL, Spencer DD, Hirsch LJ, Godwin DW, Zaveri HP. Seizure susceptibility and infraslow modulatory activity in the intracranial electroencephalogram. Epilepsia 2018; 59:2075-2085. [PMID: 30187919 DOI: 10.1111/epi.14559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/12/2018] [Accepted: 08/13/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Studies of infraslow amplitude modulations (<0.15 Hz) of band power time series suggest that these envelope correlations may form a basis for distant spatial coupling in the brain. In this study, we sought to determine how infraslow relationships are affected by antiepileptic drug (AED) taper, time of day, and seizure. METHODS We studied intracranial electroencephalographic (icEEG) data collected from 13 medically refractory adult epilepsy patients who underwent monitoring at Yale-New Haven Hospital. We estimated the magnitude-squared coherence (MSC) at <0.15 Hz of traditional EEG frequency band power time series for all electrode contact pairs to quantify infraslow envelope correlations between them. We studied, first, hour-long background icEEG epochs before and after AED taper to understand the effect of taper. Second, we analyzed the entire record for each patient to study the effect of time of day. Finally, for each patient, we reviewed the clinical record to find all seizures that were at least 6 hours removed from other seizures and analyzed infraslow envelope MSC before and after them. RESULTS Infraslow envelope MSC increased slightly, but significantly, after AED taper, and increased on average during the night and decreased during the day. It was also increased significantly in all frequency bands up to 3 hours preseizure and 1 hour postseizure as compared to background icEEG (61 seizures studied). These changes occurred for both daytime and nighttime seizures (28 daytime, 33 nighttime). Interestingly, there was significant spatial variability to these changes, with the seizure onset area peaking at 3 hours preseizure, then showing progressive desynchronization from 3 hours preseizure to 1 hour postseizure. SIGNIFICANCE Infraslow envelope analysis may be used to understand long-term changes over the course of icEEG monitoring, provide unique insight into interictal electrophysiological changes related to ictogenesis, and contribute to the development of novel seizure forecasting algorithms.
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Affiliation(s)
- Rasesh B Joshi
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Computational Neurophysiology Laboratory, Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut
| | - Robert B Duckrow
- Computational Neurophysiology Laboratory, Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut.,Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut
| | - Irina I Goncharova
- Computational Neurophysiology Laboratory, Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut.,Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut
| | - Jason L Gerrard
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Dennis D Spencer
- Comprehensive Epilepsy Center, Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut
| | - Dwayne W Godwin
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hitten P Zaveri
- Computational Neurophysiology Laboratory, Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut.,Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut
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Ghoshal S, Reynolds AS, Claassen J. Cyclic seizures – A clue to seizure termination? Clin Neurophysiol 2017; 128:1034-1036. [DOI: 10.1016/j.clinph.2017.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/23/2017] [Indexed: 01/14/2023]
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