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Schaefer SM. Rethinking our Approach to Educating New Learners in Movement Disorders Phenomenological Diagnosis. Mov Disord 2023; 38:1379-1383. [PMID: 37403965 DOI: 10.1002/mds.29530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/06/2023] Open
Affiliation(s)
- Sara M Schaefer
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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Benghanem S, Pruvost-Robieux E, Bouchereau E, Gavaret M, Cariou A. Prognostication after cardiac arrest: how EEG and evoked potentials may improve the challenge. Ann Intensive Care 2022; 12:111. [PMID: 36480063 PMCID: PMC9732180 DOI: 10.1186/s13613-022-01083-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
About 80% of patients resuscitated from CA are comatose at ICU admission and nearly 50% of survivors are still unawake at 72 h. Predicting neurological outcome of these patients is important to provide correct information to patient's relatives, avoid disproportionate care in patients with irreversible hypoxic-ischemic brain injury (HIBI) and inappropriate withdrawal of care in patients with a possible favorable neurological recovery. ERC/ESICM 2021 algorithm allows a classification as "poor outcome likely" in 32%, the outcome remaining "indeterminate" in 68%. The crucial question is to know how we could improve the assessment of both unfavorable but also favorable outcome prediction. Neurophysiological tests, i.e., electroencephalography (EEG) and evoked-potentials (EPs) are a non-invasive bedside investigations. The EEG is the record of brain electrical fields, characterized by a high temporal resolution but a low spatial resolution. EEG is largely available, and represented the most widely tool use in recent survey examining current neuro-prognostication practices. The severity of HIBI is correlated with the predominant frequency and background continuity of EEG leading to "highly malignant" patterns as suppression or burst suppression in the most severe HIBI. EPs differ from EEG signals as they are stimulus induced and represent the summated activities of large populations of neurons firing in synchrony, requiring the average of numerous stimulations. Different EPs (i.e., somato sensory EPs (SSEPs), brainstem auditory EPs (BAEPs), middle latency auditory EPs (MLAEPs) and long latency event-related potentials (ERPs) with mismatch negativity (MMN) and P300 responses) can be assessed in ICU, with different brain generators and prognostic values. In the present review, we summarize EEG and EPs signal generators, recording modalities, interpretation and prognostic values of these different neurophysiological tools. Finally, we assess the perspective for futures neurophysiological investigations, aiming to reduce prognostic uncertainty in comatose and disorders of consciousness (DoC) patients after CA.
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Affiliation(s)
- Sarah Benghanem
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Estelle Pruvost-Robieux
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Eléonore Bouchereau
- Department of Neurocritical Care, G.H.U Paris Psychiatry and Neurosciences, 1, Rue Cabanis, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Martine Gavaret
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Alain Cariou
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.462416.30000 0004 0495 1460Paris-Cardiovascular-Research-Center (Sudden-Death-Expertise-Center), INSERM U970, Paris, France
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Murphey DK, Anderson ER. The Past, Present, and Future of Tele-EEG. Semin Neurol 2022; 42:31-38. [PMID: 35576928 DOI: 10.1055/s-0041-1742242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Tele-electroencephalogram (EEG) has become more pervasive over the last 20 years due to advances in technology, both independent of and driven by personnel shortages. The professionalization of EEG services has both limited growth and controlled the quality of tele-EEG. Growing data on the conditions that benefit from brain monitoring have informed increased critical care EEG and ambulatory EEG utilization. Guidelines that marshal responsible use of still-limited resources and changes in broadband and billing practices have also shaped the tele-EEG landscape. It is helpful to characterize the drivers of tele-EEG to navigate barriers to sustainable growth and to build dynamic systems that anticipate challenges in any of the domains that expand access and enhance quality of these diagnostic services. We explore the historical factors and current trends in tele-EEG in the United States in this review.
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Critical care EEG standardized nomenclature in clinical practice: Strengths, limitations, and outlook on the example of prognostication after cardiac arrest. Clin Neurophysiol Pract 2022; 6:149-154. [PMID: 35112033 PMCID: PMC8790140 DOI: 10.1016/j.cnp.2021.03.002] [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: 11/01/2020] [Revised: 01/08/2021] [Accepted: 03/03/2021] [Indexed: 11/21/2022] Open
Abstract
Optimal use of the ACNS nomenclature implies integration of clinical information. Knowledge of pathophysiological mechanisms of EEG patterns may help interpretation. Standardized therapeutic procedures for critical care patients are needed.
We discuss the achievements of the ACNS critical care EEG nomenclature proposed in 2013 and, from a clinical angle, outline some limitations regarding translation into treatment implications. While the recently proposed updated 2021 version of the nomenclature will probable improve some uncertainty areas, a refined understanding of the mechanisms at the origin of the EEG patterns, and a multimodal integration of the nomenclature to the clinical context may help improving the rationale supporting therapeutic procedures. We illustrate these aspects on prognostication after cardiac arrest.
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Key Words
- ACNS, American Clinical Neurophysiology Society
- American Clinical Neurophysiology Society (ACNS) Standardized Terminology
- BIRD, Brief potentially ictal rhythmic discharge
- BS, Burst suppression
- Burst suppression
- CA, Cardiac arrest
- Cardiac arrest (CA)
- DWI, diffusion-weighted MRI
- ESI, electric source imaging
- GPD
- GPD, generalized periodic discharge
- GRDA, generalized rhythmic delta activity
- ICU, Intensive care unit
- ICU-EEG, intensive care unit-electroencephalography
- IIC, Ictal-Interictal Continuum
- Ictal-Interictal Continuum
- LPD, Lateralized periodic discharge
- MEG, Magneto-electroencephalography
- NCSE, Non-Convulsive Status Epilepticus
- NSE, Serum neuron-specific enolase
- PET, Positron emission tomography
- Prognostication assessment
- SE, Status epilepticus
- SPECT, Single Photon Emission Computed Tomography
- SSEP, Somatosensory evoked potentials
- WLST, Withdraw of life sustaining treatment
- fMRI, functional MRI
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Barbella G, Lee JW, Alvarez V, Novy J, Oddo M, Beers L, Rossetti AO. Prediction of regaining consciousness despite an early epileptiform EEG after cardiac arrest. Neurology 2020; 94:e1675-e1683. [DOI: 10.1212/wnl.0000000000009283] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/16/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveAfter cardiac arrest (CA), epileptiform EEG, occurring in about 1/3 of patients, often but not invariably heralds poor prognosis. We tested the hypothesis that a combination of specific EEG features identifies patients who may regain consciousness despite early epileptiform patterns.MethodsWe retrospectively analyzed a registry of comatose patients post-CA (2 Swiss centers), including those with epileptiform EEG. Background and epileptiform features in EEGs 12–36 hours or 36–72 hours from CA were scored according to the American Clinical Neurophysiology Society nomenclature. Best Cerebral Performance Category (CPC) score within 3 months (CPC 1–3 vs 4–5) was the primary outcome. Significant EEG variables were combined in a score assessed with receiver operating characteristic curves, and independently validated in a US cohort; its correlation with serum neuron-specific enolase (NSE) was also tested.ResultsOf 488 patients, 107 (21.9%) had epileptiform EEG <72 hours; 18 (17%) reached CPC 1–3. EEG 12–36 hours background continuity ≥50%, absence of epileptiform abnormalities (p< 0.00001 each), 12–36 and 36–72 hours reactivity (p< 0.0001 each), 36–72 hours normal background amplitude (p= 0.0004), and stimulus-induced discharges (p= 0.0001) correlated with favorable outcome. The combined 6-point score cutoff ≥2 was 100% sensitive (95% confidence interval [CI], 78%–100%) and 70% specific (95% CI, 59%–80%) for CPC 1–3 (area under the curve [AUC], 0.98; 95% CI, 0.94–1.00). Increasing score correlated with NSE (ρ = −0.46,p= 0.0001). In the validation cohort (41 patients), the score was 100% sensitive (95% CI, 60%–100%) and 88% specific (95% CI, 73%–97%) for CPC 1–3 (AUC, 0.96; 95% CI, 0.91–1.00).ConclusionPrognostic value of early epileptiform EEG after CA can be estimated combining timing, continuity, reactivity, and amplitude features in a score that correlates with neuronal damage.
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An Uncommon Case of Hyperammonemic Encephalopathy. Neurocrit Care 2019; 31:439-442. [DOI: 10.1007/s12028-019-00715-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sambin S, Gaspard N, Legros B, Depondt C, De Breucker S, Naeije G. Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study. Front Neurol 2019; 10:263. [PMID: 30941098 PMCID: PMC6434717 DOI: 10.3389/fneur.2019.00263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology. Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics. Participants: Fifty patients were included in the study. Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology. Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.
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Affiliation(s)
- Sara Sambin
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicolas Gaspard
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Benjamin Legros
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Chantal Depondt
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sandra De Breucker
- Geriatrics Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gilles Naeije
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Zhuo Ding J, Mallick R, Carpentier J, McBain K, Gaspard N, Brandon Westover M, Fantaneanu TA. Resident training and interrater agreements using the ACNS critical care EEG terminology. Seizure 2019; 66:76-80. [PMID: 30818180 DOI: 10.1016/j.seizure.2019.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Electroencephalography (EEG) remains the gold standard for identifying rhythmic and periodic patterns in critically ill patients. Residents have frequent exposures to EEG and critically ill patients during their training. Our study aimed to assess resident competency in the use of the American Clinical Neurophysiology Society (ACNS) critical care EEG terminology. METHODS After self-guided reading and a 2-hour session reviewing the ACNS critical care EEG Terminology training slides, 16 adult neurology residents (PGY 2-4) completed the ACNS certification test. Performance scores were reported as average percent agreement (PA%) with a previously established 5-member expert panel. Interrater agreement was calculated to gauge consensus among peers within the resident cohort. Self-reported comfort levels using the terminology were also obtained. RESULTS The overall pass rate for our cohort was 50% and the median score was 74%. The terms with the highest PA% were: seizures (86.4%), main term 1 (78%), main term 2 (74%). Interrater agreement scores (kappa values) were almost perfect for seizure, and substantial for main terms 1 and 2. CONCLUSIONS Our data suggests that with minimal investment, adult neurology residents at various stages of training can effectively learn the ACNS critical care EEG Terminology.
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Affiliation(s)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, Canada.
| | | | - Kristin McBain
- Division of Neurology, The Hospital for Sick Kids, Canada.
| | - Nicolas Gaspard
- Department of Neurology, Yale School of Medicine, United States.
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Hofmeijer J, van Putten MJAM. EEG in postanoxic coma: Prognostic and diagnostic value. Clin Neurophysiol 2016; 127:2047-55. [PMID: 26971488 DOI: 10.1016/j.clinph.2016.02.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/26/2016] [Accepted: 02/01/2016] [Indexed: 01/08/2023]
Abstract
Evolution of the EEG background pattern is a robust contributor to prediction of poor or good outcome of comatose patients after cardiac arrest. At 24h, persistent isoelectricity, low voltage activity, or burst-suppression with identical bursts predicts a poor outcome without false positives. Rapid recovery toward continuous patterns within 12h is strongly associated with a good neurological outcome. Predictive values are highest in the first 24h, despite the use of mild therapeutic hypothermia and sedative medication. Studies on reactivity or mismatch negativity have not included the EEG background pattern. Therefore, the additional predictive value of reactivity parameters remains unclear. Whether or not treatment of electrographic status epilepticus improves outcome is studied in the randomized multicenter Treatment of Electroencephalographic STatus epilepticus After cardiopulmonary Resuscitation (TELSTAR) trial (NCT02056236).
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Affiliation(s)
- J Hofmeijer
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands.
| | - M J A M van Putten
- Clinical Neurophysiology, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, The Netherlands.
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Electroencephalography and Evoked Potentials in the Intensive Care Unit, When the Steamer Becomes a Jet. J Clin Neurophysiol 2015; 32:445-6. [DOI: 10.1097/wnp.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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