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Yuan F, Damien C, Schuind S, Salvagno M, Taccone FS, Legros B, Gaspard N. Combined depth and scalp electroencephalographic monitoring in acute brain injury: Yield and prognostic value. Eur J Neurol 2024; 31:e16208. [PMID: 38270448 PMCID: PMC11235592 DOI: 10.1111/ene.16208] [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: 08/06/2023] [Revised: 10/08/2023] [Accepted: 12/28/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND AND PURPOSE Depth electroencephalography (dEEG) is an emerging neuromonitoring technology in acute brain injury (ABI). We aimed to explore the concordances between electrophysiological activities on dEEG and on scalp EEG (scEEG) in ABI patients. METHODS Consecutive ABI patients who received dEEG monitoring between 2018 and 2022 were included. Background, sporadic epileptiform discharges, rhythmic and periodic patterns (RPPs), electrographic seizures, brief potentially ictal rhythmic discharges, ictal-interictal continuum (IIC) patterns, and hourly RPP burden on dEEG and scEEG were compared. RESULTS Sixty-one ABI patients with a median dEEG monitoring duration of 114 h were included. dEEG significantly showed less continuous background (75% vs. 90%, p = 0.03), higher background amplitude (p < 0.001), more frequent rhythmic spike-and-waves (16% vs. 3%, p = 0.03), more IIC patterns (39% vs. 21%, p = 0.03), and greater hourly RPP burden (2430 vs. 1090 s/h, p = 0.01), when compared to scEEG. Among five patients with seizures on scEEG, one patient had concomitant seizures on dEEG, one had periodic discharges (not concomitant) on dEEG, and three had no RPPs on dEEG. Features and temporal occurrence of electrophysiological activities observed on dEEG and scEEG are not strongly associated. Patients with seizures and IIC patterns on dEEG seemed to have a higher rate of poor outcomes at discharge than patients without these patterns on dEEG (42% vs. 25%, p = 0.37). CONCLUSIONS dEEG can detect abnormal electrophysiological activities that may not be seen on scEEG and can be used as a complement in the neuromonitoring of ABI patients.
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Affiliation(s)
- Fang Yuan
- Neurology DepartmentSecond Affiliated Hospital of Guangzhou University of Chinese MedicineGuangzhouChina
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
- State Key Laboratory of Traditional Chinese Medicine SyndromeGuangzhouChina
| | - Charlotte Damien
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Sophie Schuind
- Service de Neurochirurgie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Michele Salvagno
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Fabio Silvio Taccone
- Service des Soins Intensifs, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Benjamin Legros
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital ErasmeUniversité Libre de BruxellesBrusselsBelgium
- Neurology DepartmentYale University School of MedicineNew HavenConnecticutUSA
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Greenblatt AS, Beniczky S, Nascimento FA. Pitfalls in scalp EEG: Current obstacles and future directions. Epilepsy Behav 2023; 149:109500. [PMID: 37931388 DOI: 10.1016/j.yebeh.2023.109500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
Although electroencephalography (EEG) serves a critical role in the evaluation and management of seizure disorders, it is commonly misinterpreted, resulting in avoidable medical, social, and financial burdens to patients and health care systems. Overinterpretation of sharply contoured transient waveforms as being representative of interictal epileptiform abnormalities lies at the core of this problem. However, the magnitude of these errors is amplified by the high prevalence of paroxysmal events exhibited in clinical practice that compel investigation with EEG. Neurology training programs, which vary considerably both in the degree of exposure to EEG and the composition of EEG didactics, have not effectively addressed this widespread issue. Implementation of competency-based curricula in lieu of traditional educational approaches may enhance proficiency in EEG interpretation amongst general neurologists in the absence of formal subspecialty training. Efforts in this regard have led to the development of a systematic, high-fidelity approach to the interpretation of epileptiform discharges that is readily employable across medical centers. Additionally, machine learning techniques hold promise for accelerating accurate and reliable EEG interpretation, particularly in settings where subspecialty interpretive EEG services are not readily available. This review highlights common diagnostic errors in EEG interpretation, limitations in current educational paradigms, and initiatives aimed at resolving these challenges.
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Affiliation(s)
- Adam S Greenblatt
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fábio A Nascimento
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Rubin M, Cutillo G, Zanandrea L, Montini F, Zanetta C, Bellini A, Cecchetti G, Fanelli GF, Falini A, Scotti R, Calloni SF, Di Bella D, Filippi M, Colombo B. Crossing the border between epileptic and vascular pathology: a report of CACNA1A-related treatment-resistant hemiplegic migraine. J Neurol 2023; 270:5639-5644. [PMID: 37466662 DOI: 10.1007/s00415-023-11877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Affiliation(s)
- M Rubin
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - G Cutillo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - L Zanandrea
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - F Montini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - C Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Bellini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Cecchetti
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - G F Fanelli
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Falini
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - R Scotti
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S F Calloni
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - D Di Bella
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - M Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - B Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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Parikh H, Hoffman K, Sun H, Zafar SF, Ge W, Jing J, Liu L, Sun J, Struck A, Volfovsky A, Rudin C, Westover MB. Effects of epileptiform activity on discharge outcome in critically ill patients in the USA: a retrospective cross-sectional study. Lancet Digit Health 2023; 5:e495-e502. [PMID: 37295971 PMCID: PMC10528143 DOI: 10.1016/s2589-7500(23)00088-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Epileptiform activity is associated with worse patient outcomes, including increased risk of disability and death. However, the effect of epileptiform activity on neurological outcome is confounded by the feedback between treatment with antiseizure medications and epileptiform activity burden. We aimed to quantify the heterogeneous effects of epileptiform activity with an interpretability-centred approach. METHODS We did a retrospective, cross-sectional study of patients in the intensive care unit who were admitted to Massachusetts General Hospital (Boston, MA, USA). Participants were aged 18 years or older and had electrographic epileptiform activity identified by a clinical neurophysiologist or epileptologist. The outcome was the dichotomised modified Rankin Scale (mRS) at discharge and the exposure was epileptiform activity burden defined as mean or maximum proportion of time spent with epileptiform activity in 6 h windows in the first 24 h of electroencephalography. We estimated the change in discharge mRS if everyone in the dataset had experienced a specific epileptiform activity burden and were untreated. We combined pharmacological modelling with an interpretable matching method to account for confounding and epileptiform activity-antiseizure medication feedback. The quality of the matched groups was validated by the neurologists. FINDINGS Between Dec 1, 2011, and Oct 14, 2017, 1514 patients were admitted to Massachusetts General Hospital intensive care unit, 995 (66%) of whom were included in the analysis. Compared with patients with a maximum epileptiform activity of 0 to less than 25%, patients with a maximum epileptiform activity burden of 75% or more when untreated had a mean 22·27% (SD 0·92) increased chance of a poor outcome (severe disability or death). Moderate but long-lasting epileptiform activity (mean epileptiform activity burden 2% to <10%) increased the risk of a poor outcome by mean 13·52% (SD 1·93). The effect sizes were heterogeneous depending on preadmission profile-eg, patients with hypoxic-ischaemic encephalopathy or acquired brain injury were more adversely affected compared with patients without these conditions. INTERPRETATION Our results suggest that interventions should put a higher priority on patients with an average epileptiform activity burden 10% or greater, and treatment should be more conservative when maximum epileptiform activity burden is low. Treatment should also be tailored to individual preadmission profiles because the potential for epileptiform activity to cause harm depends on age, medical history, and reason for admission. FUNDING National Institutes of Health and National Science Foundation.
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Affiliation(s)
- Harsh Parikh
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Kentaro Hoffman
- Deptartment of Statistics and Operation Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Wendong Ge
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lin Liu
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Institute of Natural Sciences, MOELSC, School of Mathematical Sciences and SJTU-Yale Joint Center for Biostatistics and Data Science, Shanghai Jiao Tong University, Shanghai, China
| | - Jimeng Sun
- The Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana-Champaign, IL, USA
| | - Aaron Struck
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Cynthia Rudin
- Department of Computer Science, Duke University, Durham, NC, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Satyanarayan S, Spiegel J, Hovsepian D, Markert M, Thomas R, Muffly L, Miklos D, Graber K, Scott BJ. Continuous EEG monitoring detects nonconvulsive seizure and Ictal-Interictal Continuum abnormalities in moderate to severe ICANS following systemic CAR-T therapy. Neurohospitalist 2023; 13:53-60. [PMID: 36531846 PMCID: PMC9755619 DOI: 10.1177/19418744221128852] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background and Purpose Immune Cell Effector Associated Neurotoxicity Syndrome (ICANS) is common amongst patients receiving CD19 targeted Chimeric Antigen Receptor T-cell (CAR-T) therapy. The purpose of this study is to characterize the incidence of seizures and ictal-interictal continuum (IIC) abnormalities in patients with ICANS. Methods Retrospective review of consecutive patients treated with axicabtagene ciloleucel (axi-cel) for recurrent high-grade systemic lymphoma at Stanford Medical Center between 2/2016-6/2019. Electronic medical records (EMR) were reviewed for clinical features, treatment information, EEG data, CRS (cytokine release syndrome)/ICANS severity, and clinical outcomes. Results Fifty-six patients met inclusion criteria. 85.7% of patients developed CRS, and 58.9% developed ICANS. Twenty-eight patients had EEG monitoring, of whom 26 had ICANS. Median duration of EEG monitoring was 30 hours (range .5-126 hours). Four patients (7.1%) had seizures (1 patient had a clinical generalized seizure, 2 patients had clinical and nonconvulsive seizures, and 1 patient had an isolated non-convulsive seizure). Ictal-interictal continuum abnormalities were common, of which generalized periodic discharges (GPDs) with triphasic morphology and GPDs with epileptiform morphology were most frequently seen. Generalized periodic discharges with triphasic wave morphology were found across Grade 2-3 peak ICANS severity, however the majority (86%) of patients with epileptiform GPDs had Grade 3 peak ICANS severity. Conclusions Among patients receiving axi-cel, seizure occurred in 7.1% of the total cohort, representing 12% of patients with ICANS. Ictal-interictal continuum abnormalities are also seen in patients with ICANS, most commonly GPDs. 75% of patients with seizures had nonconvulsive seizures supporting the use of continuous video EEG monitoring in this population.
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Affiliation(s)
- Sammita Satyanarayan
- Department of Neurology, Mount Sinai Icahn School of Medicine, New York, NY, USA
| | - Jay Spiegel
- Department of Medicine, University of Miami Health System, Miami, FL, USA
| | - Dominic Hovsepian
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Matthew Markert
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lori Muffly
- Department of Medicine- Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA, USA
| | - David Miklos
- Department of Medicine- Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA, USA
| | - Kevin Graber
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Brian J. Scott
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Castelli A, Placidi F, Bonomi CG, Di Giuliano F, Martorana A, Pizzicannella G, Liguori C, Manfredi N, Mari L, Pagano A, Bramato V, Mercuri NB, Izzi F. Periodic sharp wave complexes identify a distinctive phenotype in Creutzfeldt-Jacob disease. Clin Neurophysiol 2022; 143:124-132. [DOI: 10.1016/j.clinph.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 11/03/2022]
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Grigg-Damberger MM, Hussein O, Kulik T. Sleep Spindles and K-Complexes Are Favorable Prognostic Biomarkers in Critically Ill Patients. J Clin Neurophysiol 2022; 39:372-382. [PMID: 35239561 DOI: 10.1097/wnp.0000000000000830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY In this narrative review, we summarize recent research on the prognostic significance of biomarkers of sleep in continuous EEG and polysomnographic recordings in intensive care unit patients. Recent studies show the EEG biosignatures of non-rapid eye movement 2 sleep (sleep spindles and K-complexes) on continuous EEG in critically ill patients better predict functional outcomes and mortality than the ictal-interictal continuum patterns. Emergence of more complex and better organized sleep architecture has been shown to parallel neurocognitive recovery and correlate with functional outcomes in traumatic brain injury and strokes. Particularly interesting are studies which suggest intravenous dexmedetomidine may induce a more biomimetic non-rapid eye movement sleep state than intravenous propofol, potentially providing more restorative sleep and lessening delirium. Protocols to improve intensive care unit sleep and neurophysiological studies evaluating the effect of these on sleep and sleep architecture are here reviewed.
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Fatima S, Sun M, Gjini K, Struck AF. Association Between Lateralized Periodic Discharge Amplitude and Seizure on Continuous EEG Monitoring in Patients With Structural Brain Abnormality in Critical Illness. Front Neurol 2022; 13:840247. [PMID: 35370885 PMCID: PMC8966838 DOI: 10.3389/fneur.2022.840247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate the association between lateralized periodic discharge (LPD) amplitude and seizure risk on an individual level in patients with structural brain abnormality. Methods Retrospective case-control study of patients with structural brain abnormality undergoing continuous EEG monitoring was performed. We included 10 patients with LPDs and seizures as cases and 10 controls, patients with LPDs without seizure. Analysis was performed with a mixed-effects model with primary outcome measure of number of seizures per 8-h EEG epoch with fixed effects being variables of interest and random effect being subject ID. Results Epochs with seizures showed a higher absolute amplitude (corrected p = 0.04) and a higher relative amplitude (corrected p = 0.04) of LPDs. Additionally, the number of seizures was higher in epochs that had LPDs with plus features (uncorrected p = 0.002) and LPDs with higher relative amplitude (uncorrected p = 0.005). Conclusion Higher LPD amplitude is associated with increased risk of seizures on an individual patient level. A decreasing amplitude is suggestive of decreasing seizure risk, and may in fact be suggestive of decreasing ictal character of LPDs.
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Affiliation(s)
- Safoora Fatima
- Department of Neurology, Wisconsin Hospital and Clinics, University of Wisconsin, Madison, WI, United States,*Correspondence: Safoora Fatima
| | - Mengzhen Sun
- Department of Neurology, Wisconsin Hospital and Clinics, University of Wisconsin, Madison, WI, United States
| | - Klevest Gjini
- Department of Neurology, Wisconsin Hospital and Clinics, University of Wisconsin, Madison, WI, United States
| | - Aaron F. Struck
- Department of Neurology, Wisconsin Hospital and Clinics, University of Wisconsin, Madison, WI, United States,William S. Middleton Memorial Veterans Hospital, University of Wisconsin, Madison, WI, United States
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FIERAIN A, GASPARD N, LEJEUNE N, EL TAHRY R, SPEYBROECK N, DERMAUW V, FERRAO SANTOS S. Beware of nonconvulsive seizures in prolonged disorders of consciousness: long-term EEG monitoring is the key. Clin Neurophysiol 2022; 136:228-234. [DOI: 10.1016/j.clinph.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
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Muñoz‐Vendrell A, Sala‐Padró J, Jaraba S, Reynés‐Llompart G, Veciana M, Mora J, Falip M. Functional neuroimaging in nonepileptiform electroencephalographic patterns in status epilepticus. Acta Neurol Scand 2021; 144:687-694. [PMID: 34390250 DOI: 10.1111/ane.13515] [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: 04/20/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The diagnosis of nonconvulsive status epilepticus (NCSE) in patients with nonepileptiform EEG patterns remains a challenge. OBJECTIVE To evaluate the usefulness of single photon emission computerized tomography (SPECT) and its quantification (QtSPECT) in the diagnosis of NCSE. METHODS We retrospectively reviewed patients admitted with clinical suspicion of NCSE who underwent an HMPAO-SPECT simultaneously with scalp EEG showing nonepileptiform patterns, in a 5-year period. After a complete diagnostic workup, treatment, and clinical evolution, disregarding the SPECT results, patients were classified into confirmed NCSE (n = 11) and non-NCSE (n = 8). Then, we compared the EEG and SPECT results in both groups. RESULTS Lateralized rhythmic delta activity (LRDA) was predominant in the NCSE group (45.4%, p = .045), while lateralized irregular slowing was observed equally in both groups. Patients with NCSE showed significant hyperperfusion compared with non-NCSE patients (p = .026). QtSPECT correctly classified 91% of patients in NCSE and 75% patients with non-NCSE (p = .006). CONCLUSIONS Regional cerebral blood flow measured with SPECT could be useful in the diagnosis of NCSE in cases of an EEG pattern with lateralized slow activity and high clinical suspicion.
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Affiliation(s)
- Albert Muñoz‐Vendrell
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Jacint Sala‐Padró
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Sonia Jaraba
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
- Neurology Department Hospital de Viladecans Viladecans Barcelona Spain
| | - Gabriel Reynés‐Llompart
- Medical Physics Department Institut Català d’Oncologia, L’Hospitalet de Llobregat Barcelona Spain
- Image Diagnostic Institute (IDI) Nuclear Medicine Department SPECT Unit Hospital Universitari de Bellvitge Image Diagnostic Institute, L’Hospitalet de Llobregat Barcelona Spain
| | - Misericòrdia Veciana
- Neurology Service Neurophysiology Department Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Jaume Mora
- Image Diagnostic Institute (IDI) Nuclear Medicine Department SPECT Unit Hospital Universitari de Bellvitge Image Diagnostic Institute, L’Hospitalet de Llobregat Barcelona Spain
| | - Mercè Falip
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
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Using CT Perfusion in the Interictal State. J Clin Neurophysiol 2021; 38:e25-e28. [PMID: 34747885 DOI: 10.1097/wnp.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Periodic discharges seen in patients undergoing continuous EEG pose a challenge to physicians in falling into the interictal-ictal continuum and need for appropriate diagnostic and management approach. The authors herein present an 83-year-old male patient with an acute subdural hematoma who developed intermittent right upper and lower extremity weakness with change in mental status post craniotomy and hematoma evacuation. The patient was intubated and sedated with midazolam and propofol and placed on anti-seizure medications to control seizures. He was placed on continuous EEG monitoring and later developed lateralized periodic discharges. To guide treatment, a computed tomography perfusion study of the brain was performed. The results were consistent with an ictal phenomenon because of the presence of left hemispheric hyperemia. This increased cerebral blood volume and blood flow was used as a diagnostic tool to warrant more aggressive antiepileptic regimen. The patient was then started on an additional anti-seizure medication and dosages were further optimized. This led to an improvement in the patient's EEG and clinical state. There are numerous studies that show lateralized periodic discharges are seen as examples of subclinical status epilepticus and demonstrate hypermetabolism and hyperemia on positron emission tomography and single-photon emission computed tomography scans. When such imaging modalities are unavailable, cortical hyperperfusion on a computed tomography perfusion study might be a valid predictor of ongoing, subclinical, ictal activity and may be used as a complementary diagnostic tool to EEG to guide treatment.
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Continuous Versus Routine Standardized Electroencephalogram for Outcome Prediction in Critically Ill Adults: Analysis From a Randomized Trial. Crit Care Med 2021; 50:329-334. [PMID: 34582427 PMCID: PMC8797015 DOI: 10.1097/ccm.0000000000005311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. To investigate electroencephalogram (EEG) features’ relation with mortality or functional outcome after disorder of consciousness, stratifying patients between continuous EEG and routine EEG.
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Rahwan M, Edwards JC. Neuroimaging in Triphasic Waves. J Clin Neurophysiol 2021; 38:410-414. [PMID: 34155179 DOI: 10.1097/wnp.0000000000000778] [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: 11/26/2022] Open
Abstract
SUMMARY Triphasic waves can be seen in a wide range of medical conditions, particularly in metabolic encephalopathies. Neuroimaging studies provide valuable diagnostic information for neurological conditions and can also help in our understanding of anatomical substrates for these conditions. Because of practical challenges and the fact that most encephalopathies with triphasic waves are presumed to be metabolic in etiology, large studies of imaging findings associated with triphasic waves are limited. We present a summary of studies that are currently available and a discussion of insights that these studies provide.
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Affiliation(s)
- Mohamad Rahwan
- Department of Neurology, The Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Eskioglou E, Iaquaniello C, Alvarez V, Rüegg S, Schindler K, Rossetti AO, Oddo M. Electroencephalography of mechanically ventilated patients at high risk of delirium. Acta Neurol Scand 2021; 144:296-302. [PMID: 33950516 PMCID: PMC8453526 DOI: 10.1111/ane.13447] [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: 01/19/2021] [Revised: 03/30/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023]
Abstract
Objective Neurophysiological exploration of ICU delirium is limited. Here, we examined EEG characteristics of medical‐surgical critically ill patients with new‐onset altered consciousness state at high risk for ICU delirium. Materials and methods Pre‐planned analysis of non‐neurological mechanically ventilated medical‐surgical ICU subjects, who underwent a prospective multicenter randomized, controlled EEG study (NCT03129438, April 2017–November 2018). EEG characteristics, according to the 2012 ACNS nomenclature, included background activity, rhythmic periodic patterns/epileptic activity, amplitude, frequency, stimulus‐induced discharges, triphasic waves, reactivity, and NREM sleep. We explored EEG findings in delirious versus non‐delirious patients, specifically focusing on the presence of burst‐suppression and rhythmic periodic patterns (ictal‐interictal continuum), and ictal activity. Results We analyzed 91 patients (median age, 66 years) who underwent EEG because of new‐onset altered consciousness state at a median 5 days from admission; 42 patients developed delirium (46%). Burst‐suppression (10 vs 0%, p = .02), rhythmic/periodic patterns (43% vs 22%, p = .03) and epileptiform activity (7 vs 0%, p = .05) were more frequent in delirious versus non‐delirious patients. The presence of at least one of these abnormal EEG findings (32/91 patients; 35%) was associated with a significant increase in the likelihood of delirium (42 vs 15%, p = .006). Cumulative dose of sedatives and analgesics, as well as all other EEG characteristics, did not differ significantly between the two groups. Conclusion In mechanically ventilated non‐neurological critically ill patients with new‐onset alteration of consciousness, EEG showing burst‐suppression, rhythmic or periodic patterns, or seizures/status epilepticus indicate an increased risk of ICU delirium.
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Affiliation(s)
- Elissavet Eskioglou
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Carolina Iaquaniello
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
- School of Medicine and Surgery University of Milan Monza Italy
| | - Vincent Alvarez
- Department of Clinical Neuroscience University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
- Department of Neurology Hôpital du Valais Sion Switzerland
| | - Stephan Rüegg
- Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | - Kaspar Schindler
- Sleep‐Wake‐Epilepsy‐Center Department of Neurology, Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neuroscience University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
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15
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Salvioni Chiabotti P, Vicino A, Rossetti AO. Lateralized rhythmic delta activity: A peri-ictal feature beyond epilepsy. Clin Neurophysiol 2021; 132:1302-1303. [PMID: 33867255 DOI: 10.1016/j.clinph.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Paolo Salvioni Chiabotti
- Department of Clinical Neurosciences, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Alex Vicino
- Department of Clinical Neurosciences, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland.
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16
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Yazawa S, Tsuruta K, Sugimoto A, Suzuki Y, Yagi K, Matsuhashi M, Yoshimura M, Takashima H. Appearance of bitemporal periodic EEG activity in the last stage of Gerstmann-Sträussler-Scheinker syndrome (Pro102Leu): A case report. Clin Neurol Neurosurg 2021; 204:106602. [PMID: 33774505 DOI: 10.1016/j.clineuro.2021.106602] [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: 02/10/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/15/2022]
Abstract
EEG findings in advanced Gerstmann-Sträussler-Scheinker syndrome (GSS) are shown. A 56-year-old woman developed GSS symptoms and was diagnosed as having GSS with the P102L mutation at age 58. During the early stage, there were no significant EEG findings. Her clinical condition worsened and she developed akinetic mutism at age 62. The patient died of pneumonia at age 65. EEGs were recorded annually from age 61 to 65. Bilateral independent periodic discharges (BIPDs) in both temporal areas appeared at age 64. No clinical seizures were noticed. MEG showed the sharp waves of BIPDs originated independently in each temporal lobe. Other causes of BIPDs were absent.
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Affiliation(s)
- Shogo Yazawa
- Department of Neurology, Junwakai Memorial Hospital, Miyazaki, Japan.
| | - Kazuhito Tsuruta
- Department of Neurology, Junwakai Memorial Hospital, Miyazaki, Japan.
| | - Akiko Sugimoto
- Department of Neurology, Junwakai Memorial Hospital, Miyazaki, Japan.
| | - Yukiko Suzuki
- Department of Radiology, Junwakai Memorial Hospital, Miyazaki, Japan.
| | - Kazuhiro Yagi
- Department of Clinical Laboratory, Junwakai Memorial Hospital, Miyazaki, Japan.
| | - Masao Matsuhashi
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Michiyoshi Yoshimura
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
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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.
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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.
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18
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Husari KS, Johnson EL, Ritzl EK. Acute and Long-Term Outcomes of Lateralized Rhythmic Delta Activity (LRDA) Versus Lateralized Periodic Discharges (LPDs) in Critically Ill Patients. Neurocrit Care 2021; 34:201-208. [PMID: 32556854 DOI: 10.1007/s12028-020-01017-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND To assess the acute and long-term outcomes for patients with lateralized rhythmic delta activity (LRDA) compared to patients with lateralized periodic discharges (LPDs). METHODS A single-center retrospective study examining consecutive patients older than 10 years who had LRDA, LPDs, or both on continuous electroencephalographic (cEEG) between 12/01/2015 and 12/31/2017. Outcomes included inpatient mortality, functional outcome at follow-up, inpatient electrographic seizures, and the presence of new epilepsy at follow-up. Patients were classified into 4 groups: LRDA-only (without LPDs), LPDs-only (without LRDA), LRDA/LPDs, and control (without LRDA or LPDs). RESULTS Twenty-nine patients (2.7%) were in the LRDA-only group, 76 (7%) patients were in the LPDs-only group, and 25 (2.3%) patients had both patterns (LRDA/LPDs group). 68 patients were identified as a control group. Only one patient (3%) in the LRDA-only group died during their hospitalization, compared to 21 patients (28%) in the LPDs-only group, 2 (8%) LRDA/LPDs group and 7 (10%) in the control group (p 0.003). Patients in the LPDs-only group had three times higher odds of adjusted mortality compared to the control group (p 0.05), while there was no difference in the mortality odds between the LRDA-only and control groups. Patients with LRDA-only had higher odds of good functional outcome at clinic follow-up (p 0.04). When compared to control, patients with both IIC patterns (LRDA/LPDs group) had 24.3 higher odds of acute electrographic seizures (p < 0.001), followed by patients in LPDs-only (OR 12.6, p < 0.001) and then LRDA-only (OR 9.4, p = 0.002). The odds of developing epilepsy following discharge were not increased in patients with either LRDA or LPDs (p = 0.9). CONCLUSIONS Patients with LRDA had superior functional outcome compared to a higher mortality for patients with LPDs. Patients with both patterns had the highest odds of acute seizures, followed by those with only LPDs and then patients with only LRDA. There was no difference in the odds of developing new epilepsy compared to control with any IIC pattern. We hypothesize different underlying mechanisms of injury leading to the observed electrographic patterns.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe St, Meyer 2-147, Baltimore, MD, USA.
| | - Emily L Johnson
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe St, Meyer 2-147, Baltimore, MD, USA
| | - Eva K Ritzl
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe St, Meyer 2-147, Baltimore, MD, USA
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Husari KS, Ritzl EK. Lateralized Rhythmic Delta Activity in Patients With Infectious or Autoimmune Insular Lesions. Clin EEG Neurosci 2021; 52:61-65. [PMID: 33334178 DOI: 10.1177/1550059420966156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Lateralized rhythmic delta activity (LRDA) is a rare pattern on the ictal-interictal continuum (IIC) encountered in critically ill patients. Its association with acute seizures is yet to be fully explored. Insular involvement is a common finding in patients with infectious and autoimmune encephalitis. The association between acute insular lesions and the ictal-interictal continuum, particularly LRDA, has not been explored before. METHODS A case series of 4 patients with either herpetic or autoimmune encephalitis and prominent insular cortex involvement who had LRDA when monitored on continuous EEG is being presented. RESULTS Two patients had herpetic encephalitis and 2 patients had autoimmune encephalitis. All patients had either clinical or electrographic seizures with 1 patient progressing into new-onset refractory status epilepticus. CONCLUSION LRDA can be seen in patients with insular cortex acute inflammation. In this group of patients, LRDA may be associated with a higher risk of acute seizures. The presence of this otherwise not clearly epileptiform pattern should raise the clinical suspicion for the development of acute seizures. Patients with LRDA and ipsilateral insular lesions should be carefully monitored for the development of recurrent electrographic or electroclinical seizures and status epilepticus.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, USA
| | - Eva K Ritzl
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, Baltimore, MD, USA
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20
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Kamousi B, Karunakaran S, Gururangan K, Markert M, Decker B, Khankhanian P, Mainardi L, Quinn J, Woo R, Parvizi J. Monitoring the Burden of Seizures and Highly Epileptiform Patterns in Critical Care with a Novel Machine Learning Method. Neurocrit Care 2020; 34:908-917. [PMID: 33025543 PMCID: PMC8021593 DOI: 10.1007/s12028-020-01120-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Current electroencephalography (EEG) practice relies on interpretation by expert neurologists, which introduces diagnostic and therapeutic delays that can impact patients' clinical outcomes. As EEG practice expands, these experts are becoming increasingly limited resources. A highly sensitive and specific automated seizure detection system would streamline practice and expedite appropriate management for patients with possible nonconvulsive seizures. We aimed to test the performance of a recently FDA-cleared machine learning method (Claritγ, Ceribell Inc.) that measures the burden of seizure activity in real time and generates bedside alerts for possible status epilepticus (SE). METHODS We retrospectively identified adult patients (n = 353) who underwent evaluation of possible seizures with Rapid Response EEG system (Rapid-EEG, Ceribell Inc.). Automated detection of seizure activity and seizure burden throughout a recording (calculated as the percentage of ten-second epochs with seizure activity in any 5-min EEG segment) was performed with Claritγ, and various thresholds of seizure burden were tested (≥ 10% indicating ≥ 30 s of seizure activity in the last 5 min, ≥ 50% indicating ≥ 2.5 min of seizure activity, and ≥ 90% indicating ≥ 4.5 min of seizure activity and triggering a SE alert). The sensitivity and specificity of Claritγ's real-time seizure burden measurements and SE alerts were compared to the majority consensus of at least two expert neurologists. RESULTS Majority consensus of neurologists labeled the 353 EEGs as normal or slow activity (n = 249), highly epileptiform patterns (HEP, n = 87), or seizures [n = 17, nine longer than 5 min (e.g., SE), and eight shorter than 5 min]. The algorithm generated a SE alert (≥ 90% seizure burden) with 100% sensitivity and 93% specificity. The sensitivity and specificity of various thresholds for seizure burden during EEG recordings for detecting patients with seizures were 100% and 82% for ≥ 50% seizure burden and 88% and 60% for ≥ 10% seizure burden. Of the 179 EEG recordings in which the algorithm detected no seizures, seizures were identified by the expert reviewers in only two cases, indicating a negative predictive value of 99%. DISCUSSION Claritγ detected SE events with high sensitivity and specificity, and it demonstrated a high negative predictive value for distinguishing nonepileptiform activity from seizure and highly epileptiform activity. CONCLUSIONS Ruling out seizures accurately in a large proportion of cases can help prevent unnecessary or aggressive over-treatment in critical care settings, where empiric treatment with antiseizure medications is currently prevalent. Claritγ's high sensitivity for SE and high negative predictive value for cases without epileptiform activity make it a useful tool for triaging treatment and the need for urgent neurological consultation.
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Affiliation(s)
- Baharan Kamousi
- Ceribell Inc., 2483 Old Middlefield Way, Suite 120, Mountain View, CA, USA
| | | | - Kapil Gururangan
- Department of Neurology, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew Markert
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Barbara Decker
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pouya Khankhanian
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Mainardi
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James Quinn
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Raymond Woo
- Ceribell Inc., 2483 Old Middlefield Way, Suite 120, Mountain View, CA, USA
| | - Josef Parvizi
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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21
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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.
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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
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22
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23
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Sokolov E, Karschnia P, Benjamin R, Hadden RDM, Elwes RCD, Drummond L, Amin D, Paiva V, Pennisi A, Herlopian A, Frigault M, Sanderson R, Inam S, Cole AJ, Dietrich J. Language dysfunction-associated EEG findings in patients with CAR-T related neurotoxicity. BMJ Neurol Open 2020; 2:e000054. [PMID: 33681787 PMCID: PMC7871716 DOI: 10.1136/bmjno-2020-000054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Chimeric antigen receptor-modified T cells (CAR-T) have emerged as a promising immunotherapeutic approach in relapsed/refractory haematolgical malignancies. Broader application is limited by unique toxicities, notably, neurotoxicity (NTX). Language dysfunction is among the most frequent symptoms of NTX, the underlying mechanisms of which remain to be elucidated. Electroencephalogram (EEG) is an important tool to monitor for NTX and may provide insights into language dysfunction. Aim We aimed to characterise language dysfunction and define electroencephalographic signatures after CAR-T cell therapy. Methods We reviewed the clinical presentation and EEG findings of 20 adult patients presenting with language dysfunction after CAR-T cell infusion. The cohort included a subset of patients treated with investigational CD19-directed CAR-T cells for non-Hodgkin's lymphoma (n=17), acute lymphoblastic leukaemia (n=1), follicular lymphoma (n=1) and chronic lymphocytic leukaemia (n=1). Results Language dysfunction presented within 14 days of CAR-T cell infusion in 16 (84%) patients. Ten (50%) patients had mild word-finding difficulties and 10 (50%) had marked dysphasia with profound word-finding difficulties; the latter were all associated with generalised rhythmic delta activity or generalised periodic discharges on EEG. Conclusions Language dysfunction after CAR-T cell therapy is associated with generalised EEG abnormalities.
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Affiliation(s)
- Elisaveta Sokolov
- Department of Neurology, Harvard University, Cambridge, Massachusetts, USA
| | - Philipp Karschnia
- Department of Neurology, Harvard University, Cambridge, Massachusetts, USA.,Department of Neurosurgery, Ludwig Maximilians University Munich, Munchen, Bayern, Germany
| | - Reuben Benjamin
- Department of Haematology, King's College Hospital, London, UK
| | | | - Robert C D Elwes
- Neurology, King's College Hospital, London, UK.,Clinical Neurophysiology, King's College Hospital, London, UK
| | - Lee Drummond
- Department of Clinical Neurophysiology, King's College Hospital, London, UK
| | - Devyani Amin
- Department of Clinical Neurophysiology, King's College Hospital, London, UK
| | - Vitor Paiva
- Clinical Neurophysiology, King's College Hospital, London, UK
| | - Alex Pennisi
- Clinical Neurophysiology, King's College Hospital, London, UK
| | - Aline Herlopian
- Neurology/Epilepsy Division, Yale University, New Haven, Connecticut, USA
| | - Matthew Frigault
- Department of Medicine, Harvard University, Cambridge, Massachusetts, USA
| | - Robin Sanderson
- Department of Haematology, King's College Hospital, London, UK
| | - Shafqat Inam
- Department of Haematology, King's College Hospital, London, UK
| | - Andrew J Cole
- Neurology, Massachusetts General Hospital, Cambridge, Massachusetts, USA
| | - Jorg Dietrich
- Neuro-oncology/Neurology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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The PET Sandwich: Using Serial FDG-PET Scans with Interval Burst Suppression to Assess Ictal Components of Disease. Neurocrit Care 2020; 33:657-669. [PMID: 32253731 DOI: 10.1007/s12028-020-00956-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Determining the cause of refractory seizures and/or interictal continuum (IIC) findings in the critically ill patient remains a challenge. These electrographic abnormalities may represent primary ictal pathology or may instead be driven by an underlying infectious, inflammatory, or neoplastic pathology that requires targeted therapy. In these cases, it is unclear whether escalating antiepileptic therapy will be helpful or harmful. Herein, we report the use of serial [F-18] fluorodeoxyglucose positron emission tomography (FDG-PET) coupled with induced electrographic burst suppression to distinguish between primary and secondary ictal pathologies. We propose that anesthetic suppression of hypermetabolic foci suggests clinical responsiveness to escalating antiepileptic therapy, whereas non-suppressible hypermetabolic foci are suggestive of non-ictal pathologies that likely require multimodal therapy. METHODS We describe 6 patients who presented with electrographic findings of seizure or IIC abnormalities, severe neurologic injury, and clinical concern for confounding pathologies. All patients were continuously monitored on video electroencephalography (cvEEG). Five patients underwent at least two sequential FDG-PET scans of the brain: one in a baseline state and the second while under electrographic burst suppression. FDG-avid loci and EEG tracings were compared pre- and post-burst suppression. One patient underwent a single FDG-PET scan while burst-suppressed. RESULTS Four patients had initially FDG-avid foci that subsequently resolved with burst suppression. Escalation of antiepileptic therapy in these patients resulted in clinical improvement, suggesting that the foci were related to primary ictal pathology. These included clinical diagnoses of electroclinical status epilepticus, new-onset refractory status epilepticus, stroke-like migraine attacks after radiotherapy, and epilepsy secondary to inflammatory cerebral amyloid angiopathy. Conversely, two patients with high-grade EEG abnormalities had FDG-avid foci that persisted despite burst suppression. The first presented with a poor examination, fever, and concern for encephalitis. Postmortem pathology confirmed suspicion of herpes simplex virus encephalitis. The second patient presented with concern for checkpoint inhibitor-induced autoimmune encephalitis. The persistence of the FDG-avid focus, despite electrographic burst suppression, guided successful treatment through escalation of immunosuppressive therapy. CONCLUSIONS In appropriately selected patients, FDG-PET scans while in burst suppression may help dissect the underlying pathophysiologic cause of IIC findings observed on EEG and guide tailored therapy.
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25
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A tiered strategy for investigating status epilepticus. Seizure 2020; 75:165-173. [DOI: 10.1016/j.seizure.2019.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 01/03/2023] Open
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Das AS, Lee JW, Rosenthal ES, Vaitkevicius H. Successful Wean Despite Emergence of Ictal-Interictal EEG Patterns During the Weaning of Prolonged Burst-Suppression Therapy for Super-Refractory Status Epilepticus. Neurocrit Care 2019; 29:452-462. [PMID: 29948999 DOI: 10.1007/s12028-018-0552-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Management of refractory status epilepticus (SE) commonly involves the induction of burst suppression using intravenous anesthetic agents. However, the endpoints of these therapies are not well defined. Weaning anesthetic agents are complicated by the emergence of electroencephalogram (EEG) patterns along the ictal-interictal continuum (IIC), which have uncertain significance given that IIC patterns may worsen cerebral metabolism and oxygenation, have a dissociation between scalp and depth EEG recordings, or may indicate a late stage of SE itself. Determining the significance of IIC patterns in the unique context of anesthetic weaning is important to prevent the potential for unnecessarily prolonging anesthetic coma. METHODS Among 118 individuals with SE, we retrospectively identified a series of patients who underwent at least 24 h of burst-suppression therapy, experienced two or more weaning trials, and developed IIC patterns during anesthetic weaning. Anesthetic titration strategies during the emergence of these patterns were examined. RESULTS Each of the six individuals who met inclusion criteria experienced aggressive weaning despite the emergence of IIC patterns. The IIC patterns that were encountered during anesthetic weaning (including generalized and lateralized periodic discharges) are described in detail. Favorable outcomes were reported in each subject. CONCLUSION IIC patterns encountered during anesthetic weaning may be transitional and warrant observation, allowing for the emergence of more definitive clinical or electrographic results. The metabolic impact of these IIC patterns on brain activity is uncertain, but weaning strategies that treat IIC as a surrogate of recurrent SE risk further prolonging anesthetic management and its known toxicity. We speculate that these patterns may have a context-specific association with SE relapse, with less-risk conferred when these patterns are observed during the weaning of anesthetic agents after prolonged burst-suppression therapy. Other electrographic features aside from this clinical context may discriminate the risk of SE relapse, such as EEG background activity.
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Affiliation(s)
- Alvin S Das
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jong Woo Lee
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric S Rosenthal
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Faro J, Coppler PJ, Dezfulian C, Baldwin M, Molyneaux BJ, Urban A, Rittenberger JC, Callaway CW, Elmer J. Differential association of subtypes of epileptiform activity with outcome after cardiac arrest. Resuscitation 2019; 136:138-145. [PMID: 30586605 PMCID: PMC6397672 DOI: 10.1016/j.resuscitation.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Epileptiform activity is common after cardiac arrest, although intensity of electroencephalographic (EEG) monitoring may affect detection rates. Prior work has grouped these patterns together as "malignant," without considering discrete subtypes. We describe the incidence of distinct patterns in the ictal-interictal spectrum at two centers and their association with outcomes. METHODS We analyzed a retrospective cohort of comatose post-arrest patients admitted at two academic centers from January 2011 to October 2014. One center uses routine continuous EEG, the other acquires "spot" EEG at the treating physicians' discretion. We reviewed all available EEG data and classified epileptiform patterns. We abstracted antiepileptic drugs (AEDs) administrations from the electronic medical record. We compared apparent incidence of each pattern between centers, and compared outcomes (awakening from coma, survival to discharge, discharge modified Rankin Scale (mRS) 0-2) across EEG patterns and number of AEDs administered. RESULTS We included 818 patients. Routine continuous EEG was associated with a higher apparent incidence of polyspike burst-suppression (25% vs 13% P < 0.001). Frequency of other epileptiform findings did not differ. Among patients with any epileptiform pattern, only 2/258 (1%, 95%CI 0-3%) were discharged with mRS 0-2, although 24/258 (9%, 95%CI 6-14%) awakened and 36/258 (14%, 95%CI 10-19%) survived. The proportions that awakened and survived decreased in a stepwise manner with progressively worse EEG patterns (range 38% to 2% and 32% to 7%, respectively). Among patients receiving ≥3 AEDs, only 5/80 (6%, 95%CI 2-14%) awakened and 1/80 (1%, 95%CI 0-7%) had a mRS 0-2. CONCLUSION We found high rates of epileptiform EEG findings, regardless of intensity of EEG monitoring. The association of distinct ictal-interictal EEG findings with outcome was variable.
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Affiliation(s)
- John Faro
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Bradley J Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Urban
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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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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Stretz C, Sheikh Z, Maciel CB, Hirsch LJ, Gilmore EJ. Seizures, periodic and rhythmic patterns in primary intraventricular hemorrhage. Ann Clin Transl Neurol 2018; 5:1104-1111. [PMID: 30250866 PMCID: PMC6144442 DOI: 10.1002/acn3.627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/03/2018] [Accepted: 07/09/2018] [Indexed: 12/29/2022] Open
Abstract
Objective Primary intraventricular hemorrhage (pIVH) uncommonly presents with seizures. There are no prior data regarding the frequency of seizures, periodic and rhythmic patterns on continuous electroencephalography (EEG), (cEEG) in these patients. Methods We retrospectively assessed frequency of seizures, periodic discharges, and rhythmic patterns in pIVH patients undergoing cEEG monitoring. We reviewed indications for cEEG, demographics, GCS at presentation and during cEEG, modified Graeb score (mGS), presence of hydrocephalus, cEEG duration, findings and use of antiseizure medications (ASM). cEEG patterns were classified according to location and morphology. All patterns were considered “hyperexcitable” except GRDA. The ictal‐interictal continuum (IIC) was defined as LRDA, PDs, and/or SW >1 Hz but <2.5 Hz, not meeting criteria for definite electrographic seizures. Results Eleven patients had pIVH with median age of 81 (46–87) years and median mGS of 15 (9–23). Hydrocephalus was present in 7 (63.6%) and all underwent external ventricular drain (EVD) placement. Median cEEG recording was 19 (12–156) hours. Periodic or rhythmic EEG patterns were seen in 7 of 11 (64%), 5 of which were “hyperexcitable”. For the 5 patients with pIVH, EVDs, and hyperexcitable patterns, 4 (80%) were lateralized contralateral to the EVD and 1 (20%) was generalized to the EVD. The only significant difference between the hyperexcitable and non‐hyperexcitable group was duration of cEEG monitoring (P = 0.007). Interpretation Hyperexcitable patterns were common in our cases. Further research is warranted to assess prevalence of hyperexcitable patterns, their risk factors, underlying pathophysiology, and association with neuronal injury in pIVH.
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Affiliation(s)
- Christoph Stretz
- Division of Neurocritical Care and Emergency Neurology Department of Neurology Yale School of Medicine New Haven Connecticut
| | - Zubeda Sheikh
- Department of Neurology Comprehensive Epilepsy Center Yale University School of Medicine New Haven Connecticut
| | - Carolina B Maciel
- Department of Neurology Comprehensive Epilepsy Center Yale University School of Medicine New Haven Connecticut.,Division of Neurocritical Care Department of Neurology University of Florida College of Medicine Gainesville Florida
| | - Lawrence J Hirsch
- Department of Neurology Comprehensive Epilepsy Center Yale University School of Medicine New Haven Connecticut
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology Department of Neurology Yale School of Medicine New Haven Connecticut.,Department of Neurology Comprehensive Epilepsy Center Yale University School of Medicine New Haven Connecticut
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Kinney MO, Craig JJ, Kaplan PW. Non-convulsive status epilepticus: mimics and chameleons. Pract Neurol 2018; 18:291-305. [DOI: 10.1136/practneurol-2017-001796] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 12/22/2022]
Abstract
Non-convulsive status epilepticus (NCSE) is an enigmatic condition with protean manifestations. It often goes unrecognised, leading to delays in its diagnosis and treatment. The principal reason for such delay is the failure to consider and request an electroencephalogram (EEG), although occasional presentations have no scalp or surface electroencephalographic correlate. In certain settings with limited EEG availability, particularly out-of-hours, clinicians should consider treating without an EEG. Patients need a careful risk–benefit analysis to assess the risks of neuronal damage and harm versus the risks of adverse effects from various intensities of therapeutic intervention. Specialists in EEG, intensive care or epilepsy are invaluable in the management of patients with possible NCSE.
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Kinney MO, Kaplan PW. An update on the recognition and treatment of non-convulsive status epilepticus in the intensive care unit. Expert Rev Neurother 2017; 17:987-1002. [PMID: 28829210 DOI: 10.1080/14737175.2017.1369880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Non-convulsive status epilepticus (NCSE) is a complex and diverse condition which is often an under-recognised entity in the intensive care unit. When NCSE is identified the optimal treatment strategy is not always clear. Areas covered: This review is based on a literature review of the key literature in the field over the last 5-10 years. The articles were selected based on their importance to the field by the authors. Expert commentary: This review discusses the complex situations when a neurological consultation may occur in a critical care setting and provides an update on the latest evidence regarding the recognition of NCSE and the decision making around determining the aggressiveness of treatment. It also considers the ictal-interictal continuum of conditions which may be met with, particularly in the era of continuous EEG, and provides an approach for dealing with these. Suggestions for how the field will develop are discussed.
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Affiliation(s)
- Michael O Kinney
- a Department of Neurology , Belfast Health and Social Care Trust , Belfast , Northern Ireland
| | - Peter W Kaplan
- b Department of Neurology , Johns Hopkins School of Medicine , Baltimore , MD , USA
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