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Xie D, Toutant D, Ng MC. Residual Seizure Rate of Intermittent Inpatient EEG Compared to a Continuous EEG Model. Can J Neurol Sci 2024; 51:246-254. [PMID: 37282558 DOI: 10.1017/cjn.2023.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Subclinical seizures are common in hospitalized patients and require electroencephalography (EEG) for detection and intervention. At our institution, continuous EEG (cEEG) is not available, but intermittent EEGs are subject to constant live interpretation. As part of quality improvement (QI), we sought to estimate the residual missed seizure rate at a typical quaternary Canadian health care center without cEEG. METHODS We calculated residual risk percentages using the clinically validated 2HELPS2B score to risk-stratify EEGs before deriving a risk percentage using a MATLAB calculator which modeled the risk decay curve for each recording. We generated a range of estimated residual seizure rates depending on whether a pre-cEEG screening EEG was simulated, EEGs showing seizures were included, or repeat EEGs on the same patient were excluded. RESULTS Over a 4-month QI period, 499 inpatient EEGs were scored as low (n = 125), medium (n = 123), and high (n = 251) seizure risk according to 2HELPS2B criteria. Median recording duration was 1:00:06 (interquartile range, IQR 30:40-2:21:10). The model with highest residual seizure rate included recordings with confirmed electrographic seizures (median 20.83%, IQR 20.6-26.6%), while the model with lowest residual seizure rate was in seizure-free recordings (median 10.59%, IQR 4%-20.6%). These rates were significantly higher than the benchmark 5% miss-rate threshold set by 2HELPS2B (p<0.0001). CONCLUSIONS We estimate that intermittent inpatient EEG misses 2-4 times more subclinical seizures than the 2HELPS2B-determined acceptable 5% seizure miss-rate threshold for cEEG. Future research is needed to determine the impact of potentially missed seizures on clinical care.
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Affiliation(s)
- Dave Xie
- Undergraduate Medical Education, University of Manitoba, Winnipeg, MB, Canada
| | - Darion Toutant
- Biomedical Engineering Program, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus C Ng
- Biomedical Engineering Program, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
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2
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Cavusoglu D, Olgac Dundar N, Kamit F, Anil AB, Arican P, Zengin N, Gencpinar P. Evaluation of Nonconvulsive Status Epilepticus and Nonconvulsive Seizures in a Pediatric Intensive Care Unit. Clin Pediatr (Phila) 2023; 62:879-884. [PMID: 36691331 DOI: 10.1177/00099228221150687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We aimed to identify nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE) in a pediatric intensive care unit (PICU). A prospective cohort study on 35 patients who underwent continuous electroencephalographic monitoring in the PICU was done. The patients were evaluated to collect data of their demographics, clinical diagnoses, clinical seizures by electroencephalography, and neuroimaging findings. One case with NCSE and 4 cases with NCS were diagnosed among the 35 patients. The etiology of the patient with NCSE showed antiepileptic drug (AED) withdrawal. The etiology of the patients with NCS included electrical injury, head trauma, subarachnoid hemorrhage, and pneumonia. The findings suggest that younger age, epilepsy, acute structural brain abnormalities, abrupt cessation of AED, and clinically overt seizures before NCSE/NCS are associated with significant risk for NCS/NCSE. In addition, the electrical injury may also be considered as a risk factor for electrographic seizure though such a case has not yet been reported.
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Affiliation(s)
- Dilek Cavusoglu
- Department of Pediatric Neurology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyon, Turkey
| | - Nihal Olgac Dundar
- Department of Pediatric Neurology, Faculty of Medicine, Tepecik Training and Investigation Hospital, İzmir Katip Celebi University, Izmir, Turkey
| | - Fulya Kamit
- Department of Pediatric Intensive Care, İstanbul Gaziosmanpasa Hospital, Yeni Yuzyil University, Istanbul, Turkey
| | - Ayse Berna Anil
- Department of Pediatric Intensive Care, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
| | - Pinar Arican
- Department of Pediatric Neurology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Neslihan Zengin
- Department of Pediatric Intensive Care, Izmir Buca Obstetrics and Pediatrics Hospital, Izmir, Turkey
| | - Pinar Gencpinar
- Department of Pediatric Neurology, Faculty of Medicine, Tepecik Training and Investigation Hospital, İzmir Katip Celebi University, Izmir, Turkey
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Wang X, Yang F, Chen B, Jiang W. Non‐convulsive seizures and non‐convulsive status epilepticus in neuro‐intensive care unit. Acta Neurol Scand 2022; 146:752-760. [DOI: 10.1111/ane.13718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Xuan Wang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Fang Yang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Beibei Chen
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
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4
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Buchhalter J, Neuray C, Cheng JY, D’Cruz O, Datta AN, Dlugos D, French J, Haubenberger D, Hulihan J, Klein P, Komorowski RW, Kramer L, Lothe A, Nabbout R, Perucca E, der Ark PV. EEG Parameters as Endpoints in Epilepsy Clinical Trials- An Expert Panel Opinion Paper. Epilepsy Res 2022; 187:107028. [DOI: 10.1016/j.eplepsyres.2022.107028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022]
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5
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DiBacco ML, Cavan K, Sansevere AJ. Continuous Video Electroencephalography (EEG) for Event Characterization in Critically Ill Children. J Child Neurol 2022; 37:562-567. [PMID: 35635225 DOI: 10.1177/08830738221096014] [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: 11/16/2022]
Abstract
OBJECTIVE To determine features of paroxysmal events and background electroencephalographic (EEG) abnormalities associated with electroclinical seizures in critically ill children who undergo continuous video EEG to characterize clinical events. METHODS This is a prospective study of critically ill children from July 2016 to October 2018. Non-neonates with continuous video EEG indication to characterize a clinical event were included. Patients with continuous video EEG to assess for subclinical seizures due to unexplained encephalopathy and those whose event of concern were not captured on continuous video EEG were excluded. The event to be characterized was taken from documented descriptions of health care providers and classified as motor, ocular, orobuccal, autonomic, and other. In patients with more than 1 component to their paroxysmal event, the events were classified as motor plus and nonmotor plus. RESULTS One hundred patients met inclusion and exclusion criteria, with electroclinical seizures captured in 30% (30/100). The most common event to be characterized was an autonomic event in 32% (32/100). Asymmetry and epileptiform discharges were associated with electroclinical seizures (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.1-6.5, P = .03; and OR 12.5, 95% CI 4.4-35.6, P < .0001). Autonomic events alone, particularly unexplained vital sign changes, were not associated with electroclinical seizures (OR 0.3, 95% CI 0.11-0.93, P = .03). CONCLUSIONS Isolated autonomic events are unlikely to be electroclinical seizures. Details of the paroxysmal events in question can help decide which patient will benefit most from continuous video EEG based on institutional resources.
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Affiliation(s)
- Melissa L DiBacco
- Division of Epilepsy and Neurophysiology, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Kelly Cavan
- Division of Epilepsy and Neurophysiology, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Arnold J Sansevere
- Division of Epilepsy and Neurophysiology, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Children's National Hospital, Washington, DC, USA
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6
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Martin JR, Gabriel P, Gold J, Haas R, Davis S, Gonda D, Sharpe C, Wilson S, Nierenberg N, Scheuer M, Wang S. Optical Flow Estimation Improves Automated Seizure Detection in Neonatal EEG. J Clin Neurophysiol 2022; 39:235-239. [PMID: 32810002 PMCID: PMC7887141 DOI: 10.1097/wnp.0000000000000767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Existing automated seizure detection algorithms report sensitivities between 43% and 77% and specificities between 56% and 90%. The algorithms suffer from false alarms when applied to neonatal EEG because of the high degree of nurse handling and rhythmic patting used to soothe neonates. Computer vision technology that quantifies movement in real time could distinguish artifactual motion and improve automated neonatal seizure detection algorithms. METHODS The authors used video EEG recordings from 43 neonates undergoing monitoring for seizures as part of the NEOLEV2 clinical trial. The Persyst neonatal automated seizure detection algorithm ran in real time during study EEG acquisitions. Computer vision algorithms were applied to extract detailed accounts of artifactual movement of the neonate or people near the neonate though dense optical flow estimation. RESULTS Using the methods mentioned above, 197 periods of patting activity were identified and quantified, of which 45 generated false-positive automated seizure detection events. A binary patting detection algorithm was trained with a subset of 470 event videos. This supervised detection algorithm was applied to a testing subset of 187 event videos with 8 false-positive events, which resulted in a 24% reduction in false-positive automated seizure detections and a 50% reduction in false-positive events caused by neonatal care patting, while maintaining 11 of 12 true-positive seizure detection events. CONCLUSIONS This work presents a novel approach to improving automated seizure detection algorithms used during neonatal video EEG monitoring. This artifact detection mechanism can improve the ability of a seizure detector algorithm to distinguish between artifact and true seizure activity.
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Affiliation(s)
- Joel R Martin
- Department of Electrical Engineering, University of California, San Diego, La Jolla, CA
| | - Paolo Gabriel
- Department of Electrical Engineering, University of California, San Diego, La Jolla, CA
| | - Jeffrey Gold
- Department of Neurosciences, University of California, San Diego, La Jolla, CA
| | - Richard Haas
- Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Sue Davis
- Auckland District Health Board, Auckland, New Zealand
| | - David Gonda
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Cia Sharpe
- Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | | | | | | | - Sonya Wang
- Department of Neurology, University of Minnesota, Minneapolis, MN
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Loe ME, Khanmohammadi S, Morrissey MJ, Landre R, Tomko SR, Guerriero RM, Ching S. Resolving and characterizing the incidence of millihertz EEG modulation in critically ill children. Clin Neurophysiol 2022; 137:84-91. [DOI: 10.1016/j.clinph.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/28/2022] [Accepted: 02/11/2022] [Indexed: 01/30/2023]
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Damien C, Cissé FA, Depondt C, Rikir E, Legros B, Gaspard N. Duration of nonconvulsive seizures in critically ill patients. Epilepsy Behav 2021; 124:108312. [PMID: 34562685 DOI: 10.1016/j.yebeh.2021.108312] [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] [Received: 05/27/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Non-convulsive seizures (NCSz) and non-convulsive status epilepticus (NCSE) are frequent in critically ill patients. Specific temporal thresholds to define both are lacking and may be needed to guide appropriate treatment. METHOD Retrospective review of 995 NCSz captured during continuous EEG monitoring of 111 consecutive critically ill patients. Seizures were classified according to their type and underlying etiology (acute or progressive brain injury, seizure-related disorders and acute medical illness). Median and interquartile ranges [IQR] were calculated. Suggested temporal threshold for NCSE was defined as the 95 percentile of seizure duration. RESULTS Most (69%) patients had an underlying acute or progressive brain injury. The 95 percentile of seizure duration was 518 s, overall, with variation according to underlying etiology (median 86 [47-137] s for brain injury, 73 [45-115] s for seizure-related disorders, and 92 [58-223] s for acute medical illness, respectively; p = 0.0025; 95 percentile 424, 304, and 1725 s, respectively). Forty-one (37%) patients were comatose and had significantly longer seizures than non-comatose patients (median 99 [49-167] vs. 73 [46-123] s; p < 0.001; 95 percentile: 600 vs 444 s). CONCLUSION To define NCSE, a temporal threshold of 10 min in critically ill patients with a primary neurological diagnosis can be applied, while a temporal threshold of 30 min might be suitable for patients with an underlying acute medical illness.
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Affiliation(s)
- Charlotte Damien
- Neurology Department, Université Libre de Bruxelles - Cliniques Universitaires de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - Fode Abbas Cissé
- Neurology Department, Ignace Deen University Hospital Center, Conakry, Guinea
| | - Chantal Depondt
- Neurology Department, Université Libre de Bruxelles - Cliniques Universitaires de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - Estelle Rikir
- Neurology Department, Université Libre de Bruxelles - Cliniques Universitaires de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - Benjamin Legros
- Neurology Department, Université Libre de Bruxelles - Cliniques Universitaires de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - Nicolas Gaspard
- Neurology Department, Université Libre de Bruxelles - Cliniques Universitaires de Bruxelles - Hôpital Erasme, Bruxelles, Belgium; Neurology Department, Yale University, New Haven, CT, USA.
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Cavusoglu D, Sınmaz EE, Dundar NO, Can FK, Anil AB, Sarioglu B. Treatment Outcomes of Pediatric Status Epilepticus in a Tertiary Pediatric Intensive Care Unit. Pediatr Emerg Care 2021; 37:360-364. [PMID: 32149989 DOI: 10.1097/pec.0000000000001914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Status epilepticus is associated with high rates of morbidity and mortality; thus, early diagnosis and proper treatment are crucial. We aimed to study the etiology, clinical features, and treatment among pediatric patients with convulsive status epilepticus. METHODS The medical records of 100 patients were retrospectively obtained from pediatric intensive care unit. Etiology, clinical features, and treatment were interpreted by using Fisher exact test, χ2 test, and Spearman ρ correlation coefficient. RESULTS Seizures had stopped with the first-, second-, and third-line treatment in 29%, 36%, and 35% of the patients, respectively. Only phenytoin treatment was efficient; it has 32.3% rate in second-line treatment. Whereas mortality rate was 10%, morbidity rate was 14% during the follow-up. Epilepsy, hemiparesis, spastic tetraparesis, and mental retardation developed. Mortality was significantly much more in the patients with refractory seizure and cerebral palsy. Development of mental retardation was much higher in the male sex. CONCLUSIONS Phenytoin is still one of the most efficient antiepileptic drugs. If the duration of status epilepticus can be shortened by prompt treatment, neurological complications may be prevented.
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Affiliation(s)
- Dilek Cavusoglu
- From the Department of Pediatric Neurology, Faculty of Medicine, Afyon Kocatepe University, Afyon
| | - Elif Esra Sınmaz
- Department of Paediatrics, Liv Hospital, Istinye University, Istanbul
| | - Nihal Olgac Dundar
- Department of Pediatric Neurology, Tepecik Training and Investigation Hospital, Faculty of Medicine, Izmir Katip Celebi University, Izmir
| | - Fulya Kamit Can
- Department of Pediatric Intensive Care, Denizli Public Hospital, Denizli
| | - Ayse Berna Anil
- Department of Pediatric Intensive Care, Faculty of Medicine, Izmir Katip Celebi University
| | - Berrak Sarioglu
- Department of Pediatric Neurology, Tepecik Training and Investigation Hospital, Izmir, Turkey
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10
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Alterations in coordinated EEG activity precede the development of seizures in comatose children. Clin Neurophysiol 2021; 132:1505-1514. [PMID: 34023630 DOI: 10.1016/j.clinph.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/21/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to test the hypothesis that computational features of the first several minutes of EEG recording can be used to estimate the risk for development of acute seizures in comatose critically-ill children. METHODS In a prospective cohort of 118 comatose children, we computed features of the first five minutes of artifact-free EEG recording (spectral power, inter-regional synchronization and cross-frequency coupling) and tested if these features could help identify the 25 children who went on to develop acute symptomatic seizures during the subsequent 48 hours of cEEG monitoring. RESULTS Children who developed acute seizures demonstrated higher average spectral power, particularly in the theta frequency range, and distinct patterns of inter-regional connectivity, characterized by greater connectivity at delta and theta frequencies, but weaker connectivity at beta and low gamma frequencies. Subgroup analyses among the 97 children with the same baseline EEG background pattern (generalized slowing) yielded qualitatively and quantitatively similar results. CONCLUSIONS These computational features could be applied to baseline EEG recordings to identify critically-ill children at high risk for acute symptomatic seizures. SIGNIFICANCE If confirmed in independent prospective cohorts, these features would merit incorporation into a decision support system in order to optimize diagnostic and therapeutic management of seizures among comatose children.
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Bauer Huang SL, Said AS, Smyser CD, Lin JC, Guilliams KP, Guerriero RM. Seizures Are Associated With Brain Injury in Infants Undergoing Extracorporeal Membrane Oxygenation. J Child Neurol 2021; 36:230-236. [PMID: 33112194 PMCID: PMC8086759 DOI: 10.1177/0883073820966917] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Determine seizure frequency and association with neurologic outcomes in infants undergoing extracorporeal membrane oxygenation. Identify patient or clinical factors associated with seizures or brain injury on imaging. METHODS Retrospective, single-center study including infants less than 1 year of age, who underwent extracorporeal membrane oxygenation between 2012 and 2017. RESULTS A total of 104 infants met study criteria including 45 patients with continuous electroencephalographic (EEG) monitoring during their extracorporeal membrane oxygenation run and 59 infants without EEG. Seizures (electrographic-only or electro-clinical) were identified in 18 of the 45 (40%). Among the 18 infants with seizures, 14 (78%) had moderate to severe brain injury, whereas only 44% of those without seizures (12 of 27) on EEG had moderate to severe brain injury (P = .03). Cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation (ECPR), mode of extracorporeal membrane oxygenation, length of stay, survival to discharge, and congenital heart disease were not associated with seizures. One of 10 patients with cyanotic congenital heart disease due to hypoplastic left heart syndrome had seizures compared with 7 of 10 patients with non-hypoplastic left heart syndrome lesions (P = .02). Seizures were associated with moderate to severe brain injury, after adjusting for ECPR and congenital heart disease (P = .04). CONCLUSIONS Electrographic seizures were common in patients undergoing extracorporeal membrane oxygenation and higher than previously reported. Seizures were associated with moderate to severe abnormalities on imaging, after adjusting for ECPR and congenital heart disease. This study adds to recent literature describing the risk of seizures in patients on extracorporeal membrane oxygenation and highlights the presence of brain injuries that may be identified by routine EEG surveillance.
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Affiliation(s)
- Sarah L Bauer Huang
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
| | - Ahmed S Said
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Christopher D Smyser
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Radiology, 7548Washington University in St Louis, MO, USA
| | - John C Lin
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Kristin P Guilliams
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Réjean M Guerriero
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
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Din F, Lalgudi Ganesan S, Akiyama T, Stewart CP, Ochi A, Otsubo H, Go C, Hahn CD. Seizure Detection Algorithms in Critically Ill Children: A Comparative Evaluation. Crit Care Med 2020; 48:545-552. [PMID: 32205601 DOI: 10.1097/ccm.0000000000004180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the performance of commercially available seizure detection algorithms in critically ill children. DESIGN Diagnostic accuracy comparison between commercially available seizure detection algorithms referenced to electroencephalography experts using quantitative electroencephalography trends. SETTING Multispecialty quaternary children's hospital in Canada. SUBJECTS Critically ill children undergoing electroencephalography monitoring. INTERVENTIONS Continuous raw electroencephalography recordings (n = 19) were analyzed by a neurophysiologist to identify seizures. Those recordings were then converted to quantitative electroencephalography displays (amplitude-integrated electroencephalography and color density spectral array) and evaluated by six independent electroencephalography experts to determine the sensitivity and specificity of the amplitude-integrated electroencephalography and color density spectral array displays for seizure identification in comparison to expert interpretation of raw electroencephalography data. Those evaluations were then compared with four commercial seizure detection algorithms: ICTA-S (Stellate Harmonie Version 7; Natus Medical, San Carlos, CA), NB (Stellate Harmonie Version 7; Natus Medical), Persyst 11 (Persyst Development, Prescott, AZ), and Persyst 13 (Persyst Development) to determine sensitivity and specificity in comparison to amplitude-integrated electroencephalography and color density spectral array. MEASUREMENTS AND MAIN RESULTS Of the 379 seizures identified on raw electroencephalography, ICTA-S detected 36.9%, NB detected 92.3%, Persyst 11 detected 75.9%, and Persyst 13 detected 74.4%, whereas electroencephalography experts identified 76.5% of seizures using color density spectral array and 73.7% using amplitude-integrated electroencephalography. Daily false-positive rates averaged across all recordings were 4.7 with ICTA-S, 126.3 with NB, 5.1 with Persyst 11, 15.5 with Persyst 13, 1.7 with color density spectral array, and 1.5 with amplitude-integrated electroencephalography. Both Persyst 11 and Persyst 13 had sensitivity comparable to that of electroencephalography experts using amplitude-integrated electroencephalography and color density spectral array. Although Persyst 13 displayed the highest sensitivity for seizure count and seizure burden detected, Persyst 11 exhibited the best trade-off between sensitivity and false-positive rate among all seizure detection algorithms. CONCLUSIONS Some commercially available seizure detection algorithms demonstrate performance for seizure detection that is comparable to that of electroencephalography experts using quantitative electroencephalography displays. These algorithms may have utility as early warning systems that prompt review of quantitative electroencephalography or raw electroencephalography tracings, potentially leading to more timely seizure identification in critically ill patients.
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Affiliation(s)
- Farah Din
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Saptharishi Lalgudi Ganesan
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University, Okayama, Japan
| | - Craig P Stewart
- St. Joseph's Health Care London, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Ayako Ochi
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Hiroshi Otsubo
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cristina Go
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Program in Neurosciences & Mental Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Abstract
PURPOSE We aimed to determine whether clinical EEG reports obtained from children in the intensive care unit with refractory status epilepticus could provide data for comparative effectiveness research studies. METHODS We conducted a retrospective descriptive study to assess the documentation of key variables within clinical continuous EEG monitoring reports based on the American Clinical Neurophysiology Society's standardized EEG terminology for children with refractory status epilepticus from 10 academic centers. Two pediatric electroencephalographers reviewed the EEG reports. We compared reports generated using free text or templates. RESULTS We reviewed 191 EEG reports. Agreement between the electroencephalographers regarding whether a variable was described in the report ranged from fair to very good. The presence of electrographic seizures (ES) was documented in 46% (87/191) of reports, and these reports documented the time of first ES in 64% (56/87), ES duration in 72% (63/85), and ES frequency in 68% (59/87). Reactivity was documented in 16% (31/191) of reports, and it was more often documented in template than in free-text reports (40% vs. 14%, P = 0.006). Other variables were not differentially reported in template versus free-text reports. CONCLUSIONS Many key EEG features are not documented consistently in clinical continuous EEG monitoring reports, including ES characteristics and reactivity assessment. Standardization may be needed for clinical EEG reports to provide informative data for large multicenter observational studies.
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Current Status of Continuous Electroencephalographic Monitoring in Critically Ill Children. Pediatr Neurol 2019; 101:11-17. [PMID: 31493974 DOI: 10.1016/j.pediatrneurol.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/13/2019] [Accepted: 07/26/2019] [Indexed: 11/21/2022]
Abstract
The utilization of continuous electroencephalographic monitoring in critical care units has increased significantly, and several consensus statements and guidelines have been published. The use of critical care electroencephalographic monitoring has become a standard of care in many centers in the United States and other countries. The most common indication is to detect electrographic seizures and status epilepticus. Other indications include monitoring treatment efficacy in patients with electrographic seizures and status epilepticus, evaluating the degree of disturbance of function in patients with encephalopathy, monitoring brain function in patients treated with sedation and neuromuscular blocking agents, and event characterization. The urgent initiation of critical care electroencephalographic monitoring is recommended in certain clinical populations, but varies among institutions. The consensus among neurologists is to start treatment after identifying electrographic seizures or electrographic status epilepticus with or without clinical signs. However, the optimal treatment of nonconvulsive and electrographic-only seizures remains controversial. Critical care electroencephalographic monitoring has significant impact on clinical management, but there is lack of clear evidence that treatment guided by critical care electroencephalographic monitoring leads to improvement of clinical and neurodevelopmental outcome. There are substantial discrepancies among institutions on personnel and technical support used for critical care electroencephalographic monitoring. The optimal critical care electroencephalographic monitoring team should include electroencephalographers with experience in critical care electroencephalographic monitoring interpretation and appropriately trained technologists certified in electroencephalography by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists specializing in critical care electroencephalographic monitoring or long-term monitoring.
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Assessing the Feasibility of Providing a Real-Time Response to Seizures Detected With Continuous Long-Term Neonatal Electroencephalography Monitoring. J Clin Neurophysiol 2019; 36:9-13. [PMID: 30289769 DOI: 10.1097/wnp.0000000000000525] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Continuous video electroencephalography (cEEG) monitoring is the recommended gold standard of care for at-risk neonates but is not available in many Neonatal Intensive Care Units (NICUs). To conduct a randomized treatment trial of levetiracetam for the first-line treatment of neonatal seizures (the NEOLEV2 trial), we developed a monitoring infrastructure at five NICUs, implementing recent technological advancements to provide continuous video EEG monitoring and real-time response to seizure detection. Here, we report on the feasibility of providing this level of care. METHODS Twenty-five key informant interviews were conducted with study neurologists, neonatologists, coordinators, and EEG technicians from the commercial EEG monitoring company Corticare. A general inductive approach was used to analyze these qualitative data. RESULTS A robust infrastructure for continuous video EEG monitoring, remote review, and real-time seizure detection was established at all sites. At the time of this survey, 260 babies had been recruited and monitored for 2 to 6 days. The EEG technician review by the commercial EEG monitoring company was reassuring to families and neonatologists and led to earlier detection of seizures but did not reduce work load for neurologists. Neurologists found the automated neonatal seizure detector algorithm provided by the EEG software company Persyst useful, but the accuracy of the algorithm was not such that it could be used without review by human expert. Placement of EEG electrodes to initiate monitoring, especially after hours, remains problematic. CONCLUSIONS Technological advancements have made it possible to provide at-risk neonates with continuous video EEG monitoring, real-time detection of and response to seizures. However, this standard of care remains unfeasible in usual clinical practice. Chief obstacles remain starting a recording and resourcing the real-time specialist review of suspect seizures.
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16
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Conventional and quantitative EEG in status epilepticus. Seizure 2018; 68:38-45. [PMID: 30528098 DOI: 10.1016/j.seizure.2018.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To summarize the use of continuous electroencephalographic monitoring (cEEG) in the diagnosis and management of pediatric convulsive status epilepticus (CSE) and subsequent non-convulsive seizures (NCS) with a focus on available guidelines and infrastructure. In addition, we provide an overview of quantitative EEG (QEEG) for the identification of NCS in critically ill children. METHODS We performed a review of the medical literature on the use of cEEG and QEEG in pediatric CSE. This included published guideline, consensus statements, and literature focused on the use of cEEG and QEEG to detect NCS. RESULTS cEEG monitoring is recommended for prompt recognition of ongoing seizures that may be subtle, masked by pharmacologic paralysis, and or converted from convulsive seizures to NCS after administration of anti-seizure medications. Evidence indicating that high seizure burden is associated with worse outcome has motivated prompt recognition and management of NCS. The American Clinical Neurophysiology Society's consensus statement recommends a minimum of 24 h to exclude electrographic seizures, while the Neurocritical Care Society's guideline suggests 48 h in patients that are comatose. The use of QEEG amongst electroencephalographers and critical care medicine providers is increasing for NCS detection in critically ill children. The sensitivity and specificity of QEEG to detect NCS ranges from 65 to 83% and 65-92%, respectively. CONCLUSION The use of cEEG is important to the diagnosis and treatment of NCS or subtle clinical seizures after pediatric CSE. QEEG allows cEEG data to be reviewed and interpreted quickly and is a useful tool for detection of NCS after CSE.
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Affiliation(s)
- Eric T Payne
- Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN.
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18
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Mahfooz N, Weinstock A, Afzal B, Noor M, Lowy DV, Farooq O, Finnegan SG, Lakshminrusimha S. Optimal Duration of Continuous Video-Electroencephalography in Term Infants With Hypoxic-Ischemic Encephalopathy and Therapeutic Hypothermia. J Child Neurol 2017; 32:522-527. [PMID: 28112011 DOI: 10.1177/0883073816689325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Continuous video-electroencephalography (EEG) is an important diagnostic and prognostic tool in newborns with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. The optimal duration of continuous video-EEG during whole-body hypothermia is not known. We conducted a retrospective study of 35 neonates with hypoxic-ischemic encephalopathy undergoing whole-body hypothermia with continuous video-EEG. EEG ictal changes were detected in 9/35 infants (26%). Of these 9 infants, the seizures were initially observed within 30 minutes of EEG monitoring in 6 (67%), within 24 hours in 2 (22%), and during rewarming in 1 infant (11%). No new seizures were detected between 24-72 hours of therapeutic hypothermia. Background suppression was detected in 14 infants (40%) by 24 hours. In neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia, continuous video-EEG has the highest diagnostic yield within the first 24 hours and during the rewarming phase. In the absence of prior seizures or antiepileptic therapy, limiting continuous video-EEG to these periods in resource-limited settings may reduce cost during therapeutic hypothermia.
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Affiliation(s)
- Naeem Mahfooz
- 1 Department of Neurology, Division of Pediatric Neurology, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA.,2 Neurological Institute, Epilepsy Center, Cleveland, OH, USA
| | - Arie Weinstock
- 1 Department of Neurology, Division of Pediatric Neurology, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - Bushra Afzal
- 3 Division of Neonatology, Department of Pediatrics, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mariam Noor
- 1 Department of Neurology, Division of Pediatric Neurology, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - David Vargas Lowy
- 3 Division of Neonatology, Department of Pediatrics, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - Osman Farooq
- 1 Department of Neurology, Division of Pediatric Neurology, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sarah G Finnegan
- 1 Department of Neurology, Division of Pediatric Neurology, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
| | - Satyan Lakshminrusimha
- 3 Division of Neonatology, Department of Pediatrics, Women & Children's Hospital of New York, State University of New York at Buffalo, Buffalo, NY, USA
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19
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Identifying Brain Dysfunction Among Children With Acute Liver Failure-Can Spectral Electroencephalography Help? Pediatr Crit Care Med 2017; 18:88-90. [PMID: 28060158 DOI: 10.1097/pcc.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Kenney-Jung DL, Vezzani A, Kahoud RJ, LaFrance-Corey RG, Ho ML, Muskardin TW, Wirrell EC, Howe CL, Payne ET. Febrile infection-related epilepsy syndrome treated with anakinra. Ann Neurol 2016; 80:939-945. [PMID: 27770579 DOI: 10.1002/ana.24806] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 12/12/2022]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a devastating epileptic encephalopathy with limited treatment options and an unclear etiology. Anakinra is a recombinant version of the human interleukin-1 receptor antagonist used to treat autoinflammatory disorders. This is the first report of anakinra for treatment of a child with super-refractory status epilepticus secondary to FIRES. Anakinra was well tolerated and effective. Cerebral spinal fluid analysis revealed elevated levels of proinflammatory cytokines before treatment that normalized on anakinra, suggesting a potential pathogenic role for neuroinflammation in FIRES. Further studies are required to assess anakinra efficacy and dosing, and to further delineate disease etiology. Ann Neurol 2016;80:939-945.
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Affiliation(s)
- Daniel L Kenney-Jung
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | - Annamaria Vezzani
- Institute of Hospitalization and Scientific Care-Mario Negri Institute of Pharmacological Research, Milan, Italy
| | - Robert J Kahoud
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | | | - Mai-Lan Ho
- Departments of Radiology, Mayo Clinic, Rochester, MN
| | | | - Elaine C Wirrell
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
| | - Charles L Howe
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Neuroscience, Mayo Clinic, Rochester, MN.,Departments of Immunology, Mayo Clinic, Rochester, MN
| | - Eric T Payne
- Departments of Neurology, Mayo Clinic, Rochester, MN.,Departments of Pediatrics, Mayo Clinic, Rochester, MN
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