1
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Power spectrum analysis and outcomes of non-convulsive status epilepticus: a single-center study. Neurol Sci 2023; 44:287-295. [PMID: 36175811 DOI: 10.1007/s10072-022-06419-8] [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: 05/30/2022] [Accepted: 09/19/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Diagnosis of non-convulsive status epilepticus (NCSE) is challenging and outcomes during follow-up are not clear. This study aimed to conduct power spectrum analysis in NCSE and measure outcomes of patients. METHODS We searched continuous EEG monitoring (cEEG) recordings to identify patients of NCSE. An artifact-free cEEG epoch of continuous 60 s was chosen for spectral power analysis. We also collected electronic medical records of the patients for extracting clinical information. Patients recruited were followed up at least every half a year. RESULTS There were 48 patients with 64 independent NCSE episodes during different course of disease recruited in the study, with a mean age of 40.3 ± 19.1 years (range, 12-72 years), including 24 males (50%) and 24 females (50%). When the spectral power of 60 s equaled to 11.30 μV2 for predicting impairment of consciousness, (sensitivity, specificity) = (0.979, 0.625). When the spectral power of 60 s equaled to 52.70 μV2 for predicting myoclonic jerks, (sensitivity, specificity) = (0.783, 0.756). There were 27 patients (56.3%) followed up with a duration over 12 months. Nineteen patients (70.4%) continued to have seizures. Eleven (40.7%) resisted to at least two kinds of appropriate anti-seizure medication at maximum tolerated levels. Five patients with prolonged NCSE suffered from loss of brain parenchymal volume on follow-up MRI scans. CONCLUSION Spectral power analysis can be used to detect mental status and limb jerks. Early diagnosis and treatment of NCSE are important, which can influence outcomes of the patients during follow-up.
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2
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Sakathevan J, Somasundaram K, Chinyere SC, Rodríguez-Viña C, Martín-López D. Lateralized Periodic Discharges During Remifentanil Infusion. Clin EEG Neurosci 2022; 53:143-147. [PMID: 33900123 DOI: 10.1177/15500594211010624] [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] [Indexed: 11/15/2022]
Abstract
Lateralized periodic discharges (LPDs) are a common electroencephalographic (EEG) pattern in the neurointensive care unit setting. LPDs are typically observed in association with acute structural lesions of the brain with different etiologies. There are no reports describing a link between the occurrence of LPDs and the administration of remifentanil. Remifentanil is a rapid-acting pure μ-opioid receptor agonist, which is indicated to provide analgesia and sedation in mechanically ventilated patients in intensive care units. We present a case of an 84-year-old man with neuroglycopenia who developed LPDs while sedated with remifentanil. We report, for the first time, a potential relationship between remifentanil and the induction of LPDs.
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Affiliation(s)
| | | | | | - Cristina Rodríguez-Viña
- 1333Ashford and St Peter's Hospital NHS FT, Chertsey, UK.,4968St George's University Hospitals NHS FT, Chertsey, UK
| | - David Martín-López
- 1333Ashford and St Peter's Hospital NHS FT, Chertsey, UK.,4968St George's University Hospitals NHS FT, Chertsey, UK.,4262Kingston Hospital NHS FT, Chertsey, UK
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3
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Zhang K, Xu S, Zhou Y, Su T. Case Report: Triphasic Waves in a 9-Year-Old Girl With Anti-NMDAR Encephalitis. Front Neurol 2022; 13:819209. [PMID: 35145473 PMCID: PMC8821909 DOI: 10.3389/fneur.2022.819209] [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: 11/21/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Triphasic waves (TWs) are mainly described in association with metabolic encephalopathy, especially hepatic encephalopathy. Now, as different conditions including non-metabolic and structural abnormalities have been reported to be associated with TWs, the presence of TWs becomes a non-specific finding for metabolic encephalopathy. CASE PRESENTATION We report the first case of anti-NMDAR encephalitis in a 9-year-old girl presenting with TWs on EEG. The TWs background EEG lasted for about 12 h on the 40th day of the disease course. No epileptic wave was found during a series of EEG examinations. The child was discharged from the hospital and no neurological sequelae remained after a six-month follow-up. CONCLUSIONS TWs are not specific to metabolic encephalopathy, but can also occur in children with autoimmune encephalitis. This case achieved a good prognosis after the early initiation of immunotherapy.
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Affiliation(s)
- Ke Zhang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuang Xu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yalan Zhou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tangfeng Su
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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4
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Fernández-Torre JL, Kaplan PW. Atypical or Typical Triphasic Waves-Is There a Difference? A Review. J Clin Neurophysiol 2021; 38:384-398. [PMID: 34155183 DOI: 10.1097/wnp.0000000000000731] [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 The entity of triphasic waves (TWs) and TW encephalopathy has derived from the subjective art of EEG interpretation. Indeed, there are few if any guidelines regarding many different aspects of TWs. The authors seek to shed light on the nature and the diagnostic characteristics of various types of TWs, differentiating "typical" from "atypical" forms. The authors conclude that morphologies in the form of bursts of well-formed, smoothly contoured, negative-positive-negative, bilateral, symmetrical and synchronous, regular, reactive, periodic or rhythmic, 1.5 to 2.0 Hz, fronto-central, triphasic complexes with fronto-occipital lag meet the criteria for typical TWs and are highly suggestive of toxic-metabolic encephalopathies. These are most frequently hepatic, uremic, or sepsis-associated encephalopathies with multi-organ failure. In such cases, atypical TWs (frontopolar or parieto-occipital maximum, negative-positive or negative-positive-negative, asymmetric and asynchronous, unreactive, irregular, multifocal, continuous with spatiotemporal evolution, sharper and without fronto-occipital/occipito-frontal lag, or triphasic delta waves) are rarely seen. Atypical TWs are encountered in Angelman syndrome, toxic encephalopathies, hyperthyroidism/hypothyroidism, Hashimoto encephalopathy, nonconvulsive status epilepticus, dementia, sepsis-associated encephalopathy, cerebrovascular disorders, and certain boundary syndromes. Investigations describing TWs with uncommon etiologies revealed few with typical TWs, suggesting that the term "TWs" has been overused in the past. Triphasic waves arise from the interaction of multiple factors including toxic, metabolic, infectious, and structural disorders that affect circuits between thalamus and cortex. The patient's metabolic status, presence of potentially neurotoxic drugs, cerebral atrophy, white matter disease, dementia, or seizures help differentiate typical from typical TWs. Future studies will determine whether this dichotomy is heuristically and clinically helpful.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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5
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Fernández-Torre JL, Kaplan PW. Triphasic Waves: Historical Overview of an Unresolved Mystery. J Clin Neurophysiol 2021; 38:399-409. [PMID: 34155180 DOI: 10.1097/wnp.0000000000000809] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Triphasic waves are a fascinating and mysterious EEG feature. We now have to accept that, at times, epileptiform discharges may have a blunted "triphasic morphology," and that there may be great difficulty in distinguishing between these often similar forms. The aim of this review was to describe the evolution in our understanding of triphasic waves that has occurred regarding the pathophysiology of triphasic waves, their most frequent causes, and the diagnostic difficulties involved in interpretation and differentiation from nonconvulsive status epilepticus.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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6
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Miki K, Morioka T, Sakata A, Noguchi N, Mori M, Yamada T, Kai Y, Natori Y. Initial experience of a telemetry EEG amplifier (Headset™) in the emergent diagnosis of nonconvulsive status epilepticus. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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7
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Hartshorn JA, Foreman B. Generalized periodic discharges with triphasic morphology. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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8
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Schermann H, Ponomareva IV, Maltsev VG, Yakushev KB, Sherman MA. Clinical variants of limbic encephalitis. SAGE Open Med Case Rep 2019; 7:2050313X19846042. [PMID: 31105945 PMCID: PMC6501490 DOI: 10.1177/2050313x19846042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 04/03/2019] [Indexed: 01/15/2023] Open
Abstract
The clinical picture of immunomediator disorders of the central nervous system resulting from autoimmune or paraneoplastic processes is often represented by the limbic symptom complex or limbic encephalitis. The article gives a brief description of these conditions, allocated to a separate nosological group in 2007. The symptoms of limbic encephalitis include mental disorders and epileptic seizures of both convulsive and non-convulsive spectrum, up to epileptic status. Four clinical cases representative of different variants of limbic encephalitis are presented in this study, along with the discussion of epidemiology, differential diagnostics, and generally accepted patient management strategies. The diagnosis of limbic encephalitis was made on clinical grounds alone in three cases and on the presence of antibodies to N-Methyl-d-aspartic acid receptors in one case. A combination of glucocorticoid pulse therapy with prolonged use of valproic acid was successfully applied for the treatment of limbic encephalitis with non-convulsive epileptic status. Plasmapheresis was used for the treatment of limbic encephalitis with recurrent focal non-motor attacks with and without loss of consciousness, as well as for limbic encephalitis with focal motor attacks. Presented cases emphasize the need to increase the awareness of physicians of various specialties to autoimmune disorders of the nervous system. In addition, it highlights the necessity of complete diagnostic workup for a patient with impaired consciousness of unclear etiology.
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Affiliation(s)
- Haggai Schermann
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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9
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Kang JH, Husain AM, Morgenlander JC. Loss of Vestibular Ocular Reflex in Nonconvulsive Status Epilepticus. Neurocrit Care 2018; 30:675-680. [PMID: 29951957 DOI: 10.1007/s12028-018-0567-z] [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]
Abstract
BACKGROUND Electroencephalogram (EEG) findings of generalized periodic discharges (GPDs) with triphasic morphology were introduced as a metabolic phenomenon, but more recently have been associated with epileptic phenomenon. Resolution of EEG findings along with clinical improvement from treatment is diagnostic. The known causes of reversible, isolated loss of OVR include medication toxicity, lead exposure, and thiamine deficiency, but its association with nonconvulsive status epilepticus (NCSE) has never been published. Medication induced loss of OVR resolves after a 24-hour washout period. We report a case of reversible, isolated loss of vestibular ocular reflex (VOR) associated with epileptic phenomenon. METHODS This is a case report of a single patient. RESULTS A 74-year-old male with a history of complex partial seizures admitted for a pneumonectomy had a post-operative course complicated by two instances of coma, the latter associated with an isolated loss of VOR. EEG revealed GPDs with triphasic morphology initially interpreted as a metabolic phenomenon. The patient's mental status, exam and EEG findings improved after low dose infusion of propofol for tracheostomy, and he was eventually discharged at baseline neurological function. Due to this response, his coma, loss of VOR and EEG were later interpreted as a consequence of NCSE. CONCLUSION The interpretation of GPDs with triphasic wave morphology range from metabolic phenomenon to NCSE. NCSE should be highly considered on the differential for encephalopathy regardless of the circumstances. NCSE may be a potential cause of reversible, isolated loss of the VOR and an AED trial in the appropriate clinical context should be considered. This is the first report of loss of VOR possibly associated with NCSE.
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Affiliation(s)
- Jennifer H Kang
- Department of Neurology, Duke University Medical Center, DUMC 2905, Durham, NC, 27710, USA.
| | - Aatif M Husain
- Department of Neurology, Duke University Medical Center, DUMC 2905, Durham, NC, 27710, USA
- Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, NC, USA
- Neuroscience Medicine, Duke Clinical Research Institute, Durham, NC, USA
| | - Joel C Morgenlander
- Department of Neurology, Duke University Medical Center, DUMC 2905, Durham, NC, 27710, USA
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10
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O'Rourke D, Chen PM, Gaspard N, Foreman B, McClain L, Karakis I, Mahulikar A, Westover MB. Response Rates to Anticonvulsant Trials in Patients with Triphasic-Wave EEG Patterns of Uncertain Significance. Neurocrit Care 2017; 24:233-9. [PMID: 26013921 DOI: 10.1007/s12028-015-0151-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Generalized triphasic waves (TPWs) occur in both metabolic encephalopathies and non-convulsive status epilepticus (NCSE). Empiric trials of benzodiazepines (BZDs) or non-sedating AED (NSAEDs) are commonly used to differentiate the two, but the utility of such trials is debated. The goal of this study was to assess response rates of such trials and investigate whether metabolic profile differences affect the likelihood of a response. METHODS Three institutions within the Critical Care EEG Monitoring Research Consortium retrospectively identified patients with unexplained encephalopathy and TPWs who had undergone a trial of BZD and/or NSAEDs to differentiate between ictal and non-ictal patterns. We assessed responder rates and compared metabolic profiles of responders and non-responders. Response was defined as resolution of the EEG pattern and either unequivocal improvement in encephalopathy or appearance of previously absent normal EEG patterns, and further categorized as immediate (within <2 h of trial initiation) or delayed (>2 h from trial initiation). RESULTS We identified 64 patients with TPWs who had an empiric trial of BZD and/or NSAED. Most patients (71.9%) were admitted with metabolic derangements and/or infection. Positive clinical responses occurred in 10/53 (18.9%) treated with BZDs. Responses to NSAEDs occurred in 19/45 (42.2%), being immediate in 6.7%, delayed but definite in 20.0%, and delayed but equivocal in 15.6%. Overall, 22/64 (34.4%) showed a definite response to either BZDs or NSAEDs, and 7/64 (10.9%) showed a possible response. Metabolic differences of responders versus non-responders were statistically insignificant, except that the 48-h low value of albumin in the BZD responder group was lower than in the non-responder group. CONCLUSIONS Similar metabolic profiles in patients with encephalopathy and TPWs between responders and non-responders to anticonvulsants suggest that predicting responders a priori is difficult. The high responder rate suggests that empiric trials of anticonvulsants indeed provide useful clinical information. The more than twofold higher response rate to NSAEDs suggests that this strategy may be preferable to BZDs. Further prospective investigation is warranted.
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Affiliation(s)
- Deirdre O'Rourke
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Patrick M Chen
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Nicolas Gaspard
- Hôpital Erasme - ULB, Cliniques universitaires de Bruxelles, Brussels, Belgium.,Neurology Department, Yale Comprehensive Epilepsy Center, New Haven, CT, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lauren McClain
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Advait Mahulikar
- Department of Neurology, Wayne State University, Detroit, MI, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA.
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11
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Rodríguez V, Rodden MF, LaRoche SM. Ictal-interictal continuum: A proposed treatment algorithm. Clin Neurophysiol 2016; 127:2056-64. [PMID: 26971489 DOI: 10.1016/j.clinph.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/18/2016] [Accepted: 02/05/2016] [Indexed: 01/27/2023]
Abstract
The ictal-interictal continuum (IIC) is characterized by periodic and/or rhythmic EEG patterns that occur with relative high frequency in critically ill patients. Several studies have reported that some patterns seen within the continuum are independently associated with poor outcome. However there is no consensus regarding when to treat them or how aggressive treatment should be. In this review we examine peer-reviewed original scientific articles, guidelines and reviews indexed in PubMed and summarize current knowledge related to the ictal-interictal continuum. A treatment algorithm to guide management of critically ill patients with EEG patterns that fall along the IIC is proposed. The algorithm-based on best current practice in adults-takes into account associated clinical events, risk factors for developing seizures, response to medication trials and biomarkers of neuronal injury.
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Affiliation(s)
- Valia Rodríguez
- Cuban Neuroscience Center & Clinical-Surgical Hospital 'Hnos Ameijeiras', Cuba.
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12
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Trinka E, Leitinger M. Which EEG patterns in coma are nonconvulsive status epilepticus? Epilepsy Behav 2015; 49:203-22. [PMID: 26148985 DOI: 10.1016/j.yebeh.2015.05.005] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
Abstract
Nonconvulsive status epilepticus (NCSE) is common in patients with coma with a prevalence between 5% and 48%. Patients in deep coma may exhibit epileptiform EEG patterns, such as generalized periodic spikes, and there is an ongoing debate about the relationship of these patterns and NCSE. The purposes of this review are (i) to discuss the various EEG patterns found in coma, its fluctuations, and transitions and (ii) to propose modified criteria for NCSE in coma. Classical coma patterns such as diffuse polymorphic delta activity, spindle coma, alpha/theta coma, low output voltage, or burst suppression do not reflect NCSE. Any ictal patterns with a typical spatiotemporal evolution or epileptiform discharges faster than 2.5 Hz in a comatose patient reflect nonconvulsive seizures or NCSE and should be treated. Generalized periodic diacharges or lateralized periodic discharges (GPDs/LPDs) with a frequency of less than 2.5 Hz or rhythmic discharges (RDs) faster than 0.5 Hz are the borderland of NCSE in coma. In these cases, at least one of the additional criteria is needed to diagnose NCSE (a) subtle clinical ictal phenomena, (b) typical spatiotemporal evolution, or (c) response to antiepileptic drug treatment. There is currently no consensus about how long these patterns must be present to qualify for NCSE, and the distinction from nonconvulsive seizures in patients with critical illness or in comatose patients seems arbitrary. The Salzburg Consensus Criteria for NCSE [1] have been modified according to the Standardized Terminology of the American Clinical Neurophysiology Society [2] and validated in three different cohorts, with a sensitivity of 97.2%, a specificity of 95.9%, and a diagnostic accuracy of 96.3% in patients with clinical signs of NCSE. Their diagnostic utility in different cohorts with patients in deep coma has to be studied in the future. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Centre for Cognitive Neuroscience, Salzburg, Austria.
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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13
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Ng MC, Gaspard N, Cole AJ, Hoch DB, Cash SS, Bianchi M, O'Rourke DA, Rosenthal ES, Chu CJ, Westover MB. The standardization debate: A conflation trap in critical care electroencephalography. Seizure 2014; 24:52-8. [PMID: 25457454 DOI: 10.1016/j.seizure.2014.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/23/2014] [Accepted: 09/25/2014] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Persistent uncertainty over the clinical significance of various pathological continuous electroencephalography (cEEG) findings in the intensive care unit (ICU) has prompted efforts to standardize ICU cEEG terminology and an ensuing debate. We set out to understand the reasons for, and a satisfactory resolution to, this debate. METHOD We review the positions for and against standardization, and examine their deeper philosophical basis. RESULTS We find that the positions for and against standardization are not fundamentally irreconcilable. Rather, both positions stem from conflating the three cardinal steps in the classic approach to EEG, which we term "description", "interpretation", and "prescription". Using real-world examples we show how this conflation yields muddled clinical reasoning and unproductive debate among electroencephalographers that is translated into confusion among treating clinicians. We propose a middle way that judiciously uses both standardized terminology and clinical reasoning to disentangle these critical steps and apply them in proper sequence. CONCLUSION The systematic approach to ICU cEEG findings presented herein not only resolves the standardization debate but also clarifies clinical reasoning by helping electroencephalographers assign appropriate weights to cEEG findings in the face of uncertainty.
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Affiliation(s)
- Marcus C Ng
- Section of Neurology, Department of Internal Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada.
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| | - Andrew J Cole
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Daniel B Hoch
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sydney S Cash
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Matt Bianchi
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Deirdre A O'Rourke
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Eric S Rosenthal
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Catherine J Chu
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - M Brandon Westover
- Epilepsy Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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14
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Ng KWP, Wong HC, Rathakrishnan R. Should we treat patients with impaired consciousness and periodic patterns on EEG? Seizure 2014; 23:622-8. [PMID: 24882044 DOI: 10.1016/j.seizure.2014.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 04/09/2014] [Accepted: 04/30/2014] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The significance of periodic EEG patterns in patients with impaired consciousness is controversial. We aimed to determine if treating these patterns influences clinical outcome. METHOD We studied all patients who had periodic discharges on their EEG recordings from January 2007 to December 2009. Patients with clinical seizures within the preceding 24h, or with unequivocal electrographical seizure activity were excluded. Logistic regression was performed to analyze for factors associated with (a) mortality (b) functional status (c) resolution of EEG pattern. RESULTS Of the 4246 patients who had EEG, 111 (2.6%) had periodic EEG patterns. 64 met inclusion criteria. In adjusted analysis, higher mortality was associated with acute symptomatic etiology (OR 17.74, 95% CI 1.61-196.07, p=0.019), and presence of clinical seizures (OR 4.73, 95% CI 1.10-20.34, p=0.037). For each unit decrement of GCS, the odds of inpatient mortality and a poorer functional state on discharge increased by 23% (95% CI 7-37%, p=0.009) and 33% (95% CI 9-51%, p=0.011) respectively. Administration of abortive therapy was an independent risk factor for poorer functional status on discharge (adjusted OR 41.39, 95% CI 2.88-594.42, p=0.006), while patients with history of pre-existing cerebral disease appeared more likely to return to baseline functional status on discharge (unadjusted OR 5.00, 95% CI 1.40-17.86, p=0.013). CONCLUSION Treatment of periodic EEG patterns does not independently improve clinical outcome of patients with impaired conscious levels. Occurrence of seizures remote to the time of EEG and lower GCS scores independently predict poor prognoses.
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Affiliation(s)
- Kay Wei Ping Ng
- Division of Neurology, Department of Medicine, National University Hospital, Singapore.
| | - Hung Chew Wong
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Rahul Rathakrishnan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore.
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15
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Sugita T, Nakajima M, Arai D, Kuwabara K, Kawamura M. Isolated ACTH deficiency presenting with a glucocorticoid-responsive triphasic wave coma. Intern Med 2012; 51:1913-5. [PMID: 22821112 DOI: 10.2169/internalmedicine.51.7469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report the case of a 58-year-old woman who presented with acutely developed coma characterized by electroencephalographic triphasic waves (TWs) in the absence of metabolic derangement. The patient's coma and TWs were promptly resolved after the administration of glucocorticoids, and thereafter isolated ACTH deficiency was diagnosed. Isolated ACTH deficiency may present with glucocorticoid-responsive acute encephalopathy without hypoglycemia, hyponatremia, or systemic hypotension. Electroencephalographic TWs or bursts of slow waves may be a clue to the diagnosis of this rare condition in patients with coma of unknown origin.
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Affiliation(s)
- Toshihisa Sugita
- Department of Neurology, Tokyo Rosai Occupational Diseases and Injuries Hospital, Japan
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16
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Kaufman KR, Struck PJ, Wu B, Wong S. Off-label gabapentin masking ictal triphasic waves: case analysis of neuropsychiatric and electrographic correlates. Epilepsy Behav 2011; 22:606-9. [PMID: 21945412 DOI: 10.1016/j.yebeh.2011.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 10/17/2022]
Abstract
Antiepileptic drugs (AEDs) are frequently used off-label for the treatment of psychiatric, pain, and other neurological disorders. Off-label AED use may confound the diagnosis for acute neuropsychiatric changes associated with delirium by fortuitously treating, or partially treating, underlying seizure disorders while masking ictal electrographic patterns on EEGs. Standard video/EEG monitoring includes weaning from AEDs to maximize ictal activity and better determine seizure focus. We report a case of off-label gabapentin use masking ictal electrographic activity, the neuropsychiatric and electrographic consequences of discontinuing gabapentin, and the therapeutic response when gabapentin was re-initiated and titrated to a total daily dose greater than that at time of admission. Weaning from AEDs with concurrent video/EEG monitoring is an important diagnostic tool in these complex cases.
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Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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MORIOKA T, SAYAMA T, MUKAE N, HAMAMURA T, YAMAMOTO K, KIDO T, SAKATA A, SASAKI T. Nonconvulsive Status Epilepticus During Perioperative Period of Cerebrovascular Surgery. Neurol Med Chir (Tokyo) 2011; 51:171-9. [DOI: 10.2176/nmc.51.171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Tomomi KIDO
- Department of Clinical Laboratory, Kyushu Rosai Hospital
| | - Ayumi SAKATA
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital
| | - Tomio SASAKI
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University
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Interobserver agreement in the interpretation of EEG patterns in critically ill adults. J Clin Neurophysiol 2008; 25:241-9. [PMID: 18791475 DOI: 10.1097/wnp.0b013e318182ed67] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The significance of rhythmic and periodic EEG patterns in critically ill patients is unclear. A universal terminology is needed to facilitate study of these patterns, and consistent observer agreement should be demonstrated in its use. The authors evaluated inter- and intraobserver agreement using the standardized terminology (Hirsch et al., J Clin Neurophysiol 2005;22:128-135) recently proposed by the American Clinical Neurophysiology Society. Trained electroencephalographers viewed a series of 10-second EEG samples from critically ill adults (phase I), a set of >/=20-minute EEGs from the same patient cohort (phase II), and then reevaluated the first sample set (phase III). The readers used the proposed terminology to "score" each EEG. For each possible term, interobserver agreement (phases I and II) and intraobserver agreement (phase III) were calculated using pairwise kappa (kappa) values. Moderate agreement beyond chance was seen for the presence/absence of rhythmic or periodic patterns and for localization of these patterns. Agreement for other terms was slight to fair. Inter- and intraobserver agreement were consistently lower for optional terms than mandatory terms. Even when standardized terminology is used, the description of rhythmic and periodic EEG patterns varies significantly. Further refinement of the proposed terminology is required to improve inter- and intraobserver agreement.
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Grill MF, Maganti R. Cephalosporin-induced neurotoxicity: clinical manifestations, potential pathogenic mechanisms, and the role of electroencephalographic monitoring. Ann Pharmacother 2008; 42:1843-50. [PMID: 19033476 DOI: 10.1345/aph.1l307] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the clinical manifestations of cephalosporin-induced neurotoxicity, underlying potential mechanisms, role of electroencephalographic (EEG) monitoring, and management of neurotoxicity. DATA SOURCES A PubMed search (1970-May 2008) was conducted using search terms such as cephalosporins, neurotoxicity, seizures, and status epilepticus. The search was not limited to the English language and yielded approximately 187 articles. STUDY SELECTION AND DATA EXTRACTION Several case reports and case series were included to outline the salient clinical features of cephalosporin neurotoxicity. Laboratory studies investigating the potential mechanisms were also included. Reports outlining the EEG features of cephalosporin neurotoxicity were included and the role of continuous EEG monitoring was extracted. Finally, management strategies of such neurotoxicity are discussed. DATA SYNTHESIS Cephalosporin-induced neurotoxicity may manifest in a variety of clinical presentations, ranging from simple encephalopathy or mental status changes to myoclonus, asterixis, seizures, nonconvulsive status epilepticus, as well as coma. Patients who are elderly, those with renal insufficiency, and those with prior neurologic disease may be particularly prone to the neurotoxic effects. The main mechanism of neurotoxicity appears to involve gamma-aminobutyric acid A receptor inhibition, although other mechanisms may be possible. Cephalosporin neurotoxicity may be associated with a variety of EEG manifestations. Treatment mainly involves withdrawal of the offending drug, in addition to hemodialysis in patients with renal failure, and use of benzodiazepines or other anticonvulsants in patients who develop frank status epilepticus. Neurotoxicity can be prevented in high-risk cases with dosage adjustments and monitoring of serum concentrations. CONCLUSIONS Knowledge and awareness of the neurotoxic clinical manifestations, EEG findings, and underlying mechanisms are essential for clinicians in identifying and treating this potentially lethal but reversible complication of cephalosporin therapy. Further studies are needed to determine the most appropriate treatment paradigms for patients who develop status epilepticus as a result of cephalosporins.
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Affiliation(s)
- Marie Francisca Grill
- Department of Neurology, Barrow Neurological Institute/St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Cefepime-Induced Nonconvulsive Status Epilepticus: Case Report and Review. Neurocrit Care 2008; 10:347-51. [PMID: 19034700 DOI: 10.1007/s12028-008-9166-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 10/24/2008] [Indexed: 10/21/2022]
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Maganti R, Gerber P, Drees C, Chung S. Nonconvulsive status epilepticus. Epilepsy Behav 2008; 12:572-86. [PMID: 18248774 DOI: 10.1016/j.yebeh.2007.12.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 11/28/2007] [Accepted: 12/02/2007] [Indexed: 12/14/2022]
Abstract
Nonconvulsive status epilepticus (NCSE) is a heterogeneous disorder with multiple subtypes. Although attempts have been made to define and classify this disorder, there is yet no universally accepted definition or classification that encompasses all subtypes or electroclinical scenarios. Developing such a classification scheme is becoming increasingly important, because NCSE is more common than previously thought, with a bimodal peak, in children and the elderly. Recent studies have also shown a high incidence of NCSE in the critically ill. Although strong epidemiological data are lacking, NCSE constitutes about 25-50% of all cases of status epilepticus. For the purposes of this review, we propose an etiological classification for NCSE including NCSE in metabolic disorders, NCSE in coma, NCSE in acute cerebral lesions, and NCSE in those with preexisting epilepsy with or without epileptic encephalopathy. NCSE is still underrecognized, yet potentially fatal if untreated. Diagnosis can be established using an electroencephalogram (EEG) in most cases, sometimes requiring continuous monitoring. However, in comatose patients, diagnosis can be difficult, and the EEG can show a variety of rhythmic or periodic patterns, some of which are of unclear significance. Although some subtypes of NCSE are easily treatable, such as absence status epilepticus, others do not respond well to treatment, and debate exists over how aggressively clinicians should treat NCSE. In particular, the appropriate treatment of NCSE in patients who are critically ill and/or comatose is not well established, and large-scale trials are needed. Overall, further work is needed to better define NCSE, to determine which EEG patterns represent NCSE, and to establish treatment paradigms for different subtypes of NCSE.
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Affiliation(s)
- Rama Maganti
- Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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