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Wagner AS, Baumann SM, Semmlack S, Frei AI, Rüegg S, Hunziker S, Marsch S, Sutter R. Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study. Neurology 2023; 100:e1763-e1775. [PMID: 36878696 PMCID: PMC10136011 DOI: 10.1212/wnl.0000000000206838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/06/2022] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the frequency of status epilepticus (SE) among seizing critically ill adult patients and to determine clinical differences between patients with isolated seizures and patients with SE in the intensive care unit (ICU). METHODS From 2015 to 2020, all consecutive adult ICU patients at a Swiss tertiary care center with isolated seizures or SE as reported by intensivists and/or consulting neurologists were identified by screening of all digital medical, ICU, and EEG records. Patients aged <18 years and patients with myoclonus due to hypoxic-ischemic encephalopathy but without seizures on EEG were excluded. The frequency of isolated seizures, SE, and clinical characteristics at seizure onset associated with SE were the primary outcomes. Uni- and multivariable logistic regression was performed to identify associations with the emergence of SE. RESULTS Among 404 patients with seizures, 51% had SE. Compared with patients with isolated seizures, patients with SE had a lower median Charlson Comorbidity Index (CCI) (3 vs 5, p < 0.001), fewer fatal etiologies (43.6% vs 80.5%, p < 0.001), higher median Glasgow coma scores (7 vs 5, p < 0.001), fever more frequently (27.5% vs 7.5%, p < 0.001), shorter median ICU and hospital stay (ICU: 4 vs 5 days, p = 0.039; hospital stay: 13 vs 15 days, p = 0.045), and recovered to premorbid function more often (36.8% vs 17%, p < 0.001). Multivariable analyses revealed decreased odds ratios (ORs) for SE with increasing CCI (OR 0.91, 95% CI 0.83-0.99), fatal etiology (OR 0.15, 95% CI 0.08-0.29), and epilepsy (OR 0.32, 95% CI 0.16-0.63). Systemic inflammation was an additional association with SE after excluding patients with seizures as the reason for ICU admission (ORfor CRP 1.01, 95% CI 1.00-1.01; ORfor fever 7.35, 95% CI 2.84-19.0). Although fatal etiologies and increasing CCI remained associated with low odds for SE after excluding anesthetized patients and hypoxic-ischemic encephalopathy, inflammation remained associated in all subgroups except patients with epilepsy. DISCUSSION Among all ICU patients with seizures, SE emerged frequently and seen in every second patient. Besides the unexpected low odds for SE with higher CCI, fatal etiology, and epilepsy, the association of inflammation with SE in the critically ill without epilepsy represents a potential treatment target and deserves further attention.
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Affiliation(s)
- Anna S Wagner
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja I Frei
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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Skhirtladze-Dworschak K, Felli A, Aull-Watschinger S, Jung R, Mouhieddine M, Zuckermann A, Tschernko E, Dworschak M, Pataraia E. The Impact of Nonconvulsive Status Epilepticus after Cardiac Surgery on Outcome. J Clin Med 2022; 11:jcm11195668. [PMID: 36233535 PMCID: PMC9572147 DOI: 10.3390/jcm11195668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Neurological complications after heart surgery are associated with tremendous morbidity and mortality. Nonconvulsive status epilepticus (NCSE), which can only be verified by EEG, may cause secondary brain damage. Its frequency and its impact on outcomes after cardiac surgery is still unclear. We collected the neurological files and clinical data of all our patients after heart surgery who, in the course of their ICU stay, had been seen by a neurologist who ordered an EEG. Within 18 months, 1457 patients had cardiac surgery on cardiopulmonary bypass. EEG was requested for 89 patients. Seizures were detected in 39 patients and NCSE was detected in 11 patients. Open heart surgery was performed in all 11 NSCE patients, of whom eight showed concomitant brain insults. None had a history of epilepsy. Despite the inhibition of seizure activity with antiseizure medication, clinical improvement was only noted in seven NCSE patients, three of whom were in cerebral performance category 2 and four in category 3 at hospital discharge. The four patients without neurological benefit subsequently died in the ICU. The occurrence of NCSE after open cardiac surgery is significant and frequently associated with brain injury. It seems prudent to perform EEG studies early to interrupt seizure activity and mitigate secondary cerebral injury.
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Affiliation(s)
- Keso Skhirtladze-Dworschak
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, General Hospital Vienna, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Alessia Felli
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, A-1090 Vienna, Austria
| | | | - Rebekka Jung
- Department of Neurology, Medical University of Vienna, A-1090 Vienna, Austria
| | - Mohamed Mouhieddine
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, General Hospital Vienna, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, A-1090 Vienna, Austria
| | - Edda Tschernko
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, General Hospital Vienna, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Martin Dworschak
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, General Hospital Vienna, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-41090; Fax: +43-1-40400-41100
| | - Ekaterina Pataraia
- Department of Neurology, Medical University of Vienna, A-1090 Vienna, Austria
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Wagner AS, Semmlack S, Frei A, Rüegg S, Marsch S, Sutter R. Seizures and risks for recurrence in critically ill patients: an observational cohort study. J Neurol 2022; 269:4185-4194. [PMID: 35235003 PMCID: PMC9293863 DOI: 10.1007/s00415-022-11038-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
Background To assess the frequency and clinical characteristics of seizures in adult critically ill patients, to identify predictors of recurrent seizures not transforming into status epilepticus and to characterize their effects on course and outcome.
Methods ICU patients at a Swiss academic medical center with seizures not transforming into status epilepticus from 2015 to 2020 were included. Recurrent seizures and associated clinical characteristics were primary, death, and return to premorbid neurologic function were secondary outcomes.
Results Two hundred of 26,370 patients (0.8%) with a median age of 65 years had seizures during ICU stay. Seizure semiology was described in 82% (49% generalized; 33% focal) with impaired consciousness during seizures in 80% and motor symptoms in 62%. Recurrent seizures were reported in 71% (36% on EEG) and associated with longer mechanical ventilation (p = 0.031), higher consultation rate by neurologists (p < 0.001), and increased use of EEG (p < 0.001) when compared to single seizures. The use of EEG was not associated with secondary outcomes. Acidosis at seizure onset and prior emergency operations were associated with decreased odds for seizure recurrence (OR 0.43; 95% CI 0.20–0.94 and OR 0.48; 95% CI 0.24–0.97). Epilepsy had increased odds for seizure recurrence (OR 3.56; 95% CI 1.14–11.16).
Conclusions Seizures in ICU patients are infrequent, but mostly recurrent, and associated with higher resource utilization. Whenever seizures are observed, clinicians should be vigilant about the increased risk of seizures recurrence and the need for antiseizure treatment must be carefully discussed. While known epilepsy seems to promote recurrent seizures, our results suggest that both acidosis and previous emergency surgery seem to have protective/antiseizure effects. Trial registration Clinicaltrials.gov (No. NCT03860467).
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Affiliation(s)
- Anna S Wagner
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Saskia Semmlack
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Anja Frei
- Department of Intensive Care, University Hospital Basel, 4031, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Department of Intensive Care, University Hospital Basel, 4031, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, Basel, Switzerland. .,Department of Intensive Care, University Hospital Basel, 4031, Basel, Switzerland. .,Medical Faculty, University of Basel, Basel, Switzerland.
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Zhang L, Zheng W, Chen F, Bai X, Xue L, Liang M, Geng Z. Associated Factors and Prognostic Implications of Non-convulsive Status Epilepticus in Ischemic Stroke Patients With Impaired Consciousness. Front Neurol 2022; 12:795076. [PMID: 35069425 PMCID: PMC8777101 DOI: 10.3389/fneur.2021.795076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Non-convulsive status epilepticus (NCSE) is common in patients with disorders of consciousness and can cause secondary brain injury. Our study aimed to explore the determinants and prognostic significance of NCSE in stroke patients with impaired consciousness. Method: Consecutive ischemic stroke patients with impaired consciousness who were admitted to a neuro intensive care unit were enrolled for this study. Univariate and multivariable logistic regression were used to identify factors associated with NCSE and their correlation with prognosis. Results: Among the 80 patients studied, 20 (25%) died during hospitalization, and 51 (63.75%) had unfavorable outcomes at the 3-month follow-up. A total of 31 patients (38.75%) developed NCSE during 24-h electroencephalogram (EEG) monitoring. Logistic regression revealed that NCSE was significantly associated with an increased risk of death during hospital stay and adverse outcomes at the 3-month follow-up. Patients with stroke involving the cerebral cortex or those who had a severely depressed level of consciousness were more prone to epileptogenesis after stroke. Conclusion: Our results suggest that NCSE is a common complication of ischemic stroke, and is associated with both in-hospital mortality and dependency at the 3-month follow-up. Long-term video EEG monitoring of stroke patients is, therefore required, especially for those with severe consciousness disorders (stupor or coma) or cortical injury.
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Affiliation(s)
- Liren Zhang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wensi Zheng
- Shanghai Key Laboratory of Psychotic Disorders, Department of Psychiatry, Shanghai Mental Health Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Chen
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaolin Bai
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lixia Xue
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Mengke Liang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai, China
| | - Zhi Geng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Holm‐Yildiz S, Richter Hansen J, Thonon V, Beniczky S, Fabricius M, Sidaros A, Kondziella D. Does continuous electroencephalography influence therapeutic decisions in neurocritical care? Acta Neurol Scand 2021; 143:290-297. [PMID: 33091148 DOI: 10.1111/ane.13364] [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: 02/04/2020] [Revised: 03/23/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In the neurocritical care unit (neuro-ICU), the impact of continuous EEG (cEEG) on therapeutic decisions and prognostication, including outcome prediction using the Status Epilepticus Severity Score (STESS), is poorly investigated. We studied to what extent cEEG contributes to treatment decisions, and how this relates to clinical outcome and the use of STESS in neurocritical care. METHODS We included patients admitted to the neuro-ICU or neurological step-down unit of a tertiary referral hospital between 05/2013 and 06/2015. Inclusion criteria were ≥20 h of cEEG monitoring and age ≥15 years. Exclusion criteria were primary epileptic and post-cardiac arrest encephalopathies. RESULTS Ninety-eight patients met inclusion criteria, 80 of which had status epilepticus, including 14 with super-refractory status. Median length of cEEG monitoring was 50 h (range 21-374 h). Mean STESS was lower in patients with favorable outcome 1 year after discharge (modified Rankin Scale [mRS] 0-2) compared to patients with unfavorable outcome (mRS 3-6), albeit not statistically significant (mean STESS 2.3 ± 2.1 vs 3.6 ± 1.7, p = 0.09). STESS had a sensitivity of 80%, a specificity of 42%, and a negative predictive value of 93% for outcome. cEEG results changed treatment decisions in 76 patients, including escalation of antiepileptic treatment in 65 and reduction in 11 patients. CONCLUSION Status Epilepticus Severity Score had a high negative predictive value but low sensitivity, suggesting that STESS should be used cautiously. Of note, cEEG results altered clinical decision-making in three of four patients, irrespective of the presence or absence of status epilepticus, confirming the clinical value of cEEG in neurocritical care.
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Affiliation(s)
- Sonja Holm‐Yildiz
- Department of Neurology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Julie Richter Hansen
- Department of Neurology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Vanessa Thonon
- Department of Clinical Neurophysiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Neurophysiology Vall d'Hebron University Hospital Barcelona Spain
| | - Sándor Beniczky
- Department of Clinical Neurophysiology Danish Epilepsy Centre Dianalund Denmark
- Aarhus University Hospital Aarhus Denmark
| | - Martin Fabricius
- Department of Clinical Neurophysiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Annette Sidaros
- Department of Neurology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Clinical Neurophysiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Daniel Kondziella
- Department of Neurology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Faculty of Health and Medical Science Copenhagen University Copenhagen Denmark
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Abstract
Continuous vs Routine Electroencephalogram in Critically Ill Adults With Altered Consciousness and No Recent Seizure: A Multicenter Randomized Clinical Trial Rossetti AO, Schindler K, Sutter R, Rüegg S, Zubler F, Novy J, Oddo M, Warpelin-Decrausaz L, Alvarez V. JAMA Neurol. 2020;77(10):1-8. doi:10.1001/jamaneurol.2020.2264 Importance: In critically ill patients with altered consciousness, continuous electroencephalogram (cEEG) improves seizure detection but is resource-consuming compared with routine EEG (rEEG). It is also uncertain whether cEEG has an effect on outcome. Objective: To assess whether cEEG is associated with reduced mortality compared with rEEG. Design, Setting, and Participants: The pragmatic multicenter Continuous EEG Randomized Trial in Adults was conducted between 2017 and 2018, with follow-up of 6 months. Outcomes were assessed by interviewers blinded to interventions. The study took place at 4 tertiary hospitals in Switzerland (intensive and intermediate care units). Depending on investigators’ availability, we pragmatically recruited critically ill adults having Glasgow Coma Scale scores of 11 or less or Full Outline of Responsiveness score of 12 or less, without recent seizures or status epilepticus. They had cerebral (eg, brain trauma, cardiac arrest, hemorrhage, or stroke) or noncerebral conditions (eg, toxic-metabolic or unknown etiology), and EEG was requested as part of standard care. An independent physician provided emergency informed consent. Interventions: Participants were randomized 1:1 to cEEG for 30 to 48 hours versus 2 rEEGs (20 minutes each), interpreted according to standardized American Clinical Neurophysiology Society guidelines. Main Outcomes and Measures: Mortality at 6 months represented the primary outcome. Secondary outcomes included interictal and ictal features detection and change in therapy. Results: We analyzed 364 (33% women; mean [SD] age, 63 [15] years) patients. At 6 months, mortality was 89 of 182 in those with cEEG and 88 of 182 in those with rEEG (adjusted relative risk [RR]: 1.02; 95% CI: 0.83-1.26; P = .85). Exploratory comparisons within subgroups stratifying patients according to age, premorbid disability, comorbidities on admission, deeper consciousness reduction, and underlying diagnoses revealed no significant effect modification. Continuous EEG was associated with increased detection of interictal features and seizures (adjusted RR: 1.26; 95% CI: 1.08-1.15; P = .004 and 3.37; 95% CI: 1.63-7.00; P = .001, respectively) and more frequent adaptations in anti-seizure therapy (RR: 1.84; 95% CI: 1.12-3.00; P = .01). Conclusions and Relevance: This pragmatic trial shows that in critically ill adults with impaired consciousness and no recent seizure, cEEG leads to increased seizure detection and modification of anti-seizure treatment but is not related to improved outcome compared with repeated rEEG. Pending larger studies, rEEG may represent a valid alternative to cEEG in centers with limited resources.
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