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Luccarelli J, Smith JR, Fricchione G, Westover MB. Generalized Periodic Discharges Associated With Catatonia and Delirium: A Case Series. J Neuropsychiatry Clin Neurosci 2024:appineuropsych20230174. [PMID: 38720623 DOI: 10.1176/appi.neuropsych.20230174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
OBJECTIVE Generalized periodic discharges are a repeated and generalized electroencephalography (EEG) pattern that can be seen in the context of altered mental status. This article describes a series of five individuals with generalized periodic discharges who demonstrated signs and symptoms of catatonia, a treatable neuropsychiatric condition. METHODS Inpatients with a clinical diagnosis of catatonia, determined with the Bush-Francis Catatonia Rating Scale (BFCRS), and EEG recordings with generalized periodic discharges were analyzed in a retrospective case series. RESULTS Five patients with catatonia and generalized periodic discharges on EEG were evaluated from among 106 patients with catatonia and contemporaneous EEG measurements. Four of these patients showed an improvement in catatonia severity when treated with benzodiazepines, with an average reduction of 6.75 points on the BFCRS. CONCLUSIONS Among patients with generalized periodic discharges, catatonia should be considered, in the appropriate clinical context. Patients with generalized periodic discharges and catatonia may benefit from treatment with empiric trials of benzodiazepines.
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Affiliation(s)
- James Luccarelli
- Departments of Psychiatry (Luccarelli, Fricchione) and Neurology (Westover), Harvard Medical School, Boston; Department of Psychiatry, Massachusetts General Hospital, Boston (Luccarelli, Fricchione); Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Vanderbilt University Medical Center at Village of Vanderbilt, and Vanderbilt Kennedy Center, Vanderbilt University, Nashville, Tenn. (Smith); Department of Neurology, Beth Israel Deaconess Medical Center, Boston (Westover)
| | - Joshua R Smith
- Departments of Psychiatry (Luccarelli, Fricchione) and Neurology (Westover), Harvard Medical School, Boston; Department of Psychiatry, Massachusetts General Hospital, Boston (Luccarelli, Fricchione); Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Vanderbilt University Medical Center at Village of Vanderbilt, and Vanderbilt Kennedy Center, Vanderbilt University, Nashville, Tenn. (Smith); Department of Neurology, Beth Israel Deaconess Medical Center, Boston (Westover)
| | - Gregory Fricchione
- Departments of Psychiatry (Luccarelli, Fricchione) and Neurology (Westover), Harvard Medical School, Boston; Department of Psychiatry, Massachusetts General Hospital, Boston (Luccarelli, Fricchione); Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Vanderbilt University Medical Center at Village of Vanderbilt, and Vanderbilt Kennedy Center, Vanderbilt University, Nashville, Tenn. (Smith); Department of Neurology, Beth Israel Deaconess Medical Center, Boston (Westover)
| | - M Brandon Westover
- Departments of Psychiatry (Luccarelli, Fricchione) and Neurology (Westover), Harvard Medical School, Boston; Department of Psychiatry, Massachusetts General Hospital, Boston (Luccarelli, Fricchione); Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Vanderbilt University Medical Center at Village of Vanderbilt, and Vanderbilt Kennedy Center, Vanderbilt University, Nashville, Tenn. (Smith); Department of Neurology, Beth Israel Deaconess Medical Center, Boston (Westover)
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Kim JH, Kim T, Kim W, Kim SH, Hong YJ, Lim E, Bae DW, Noh SM, Lee J. The incidence and predictors of antibiotic-associated encephalopathy: a multicenter hospital-based study. Sci Rep 2024; 14:8747. [PMID: 38627483 PMCID: PMC11021399 DOI: 10.1038/s41598-024-59555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
This study aimed to evaluate the incidence and likelihood of antibiotic-associated encephalopathy (AAE), comparing rates among the classes of antibiotics in monotherapy or in combination therapy. We also investigated the associations between the incidence of AAE and the glomerular filtration rate (GFR) and electroencephalogram features. Consecutive admissions that used any kind of antibiotics to treat infectious diseases were identified from six hospitals. We classified antibiotics according to three distinct pathophysiologic mechanisms and clinical subtypes. We searched for the incidence of AAE as the primary outcome. A total of 97,433 admission cases among 56,038 patients was identified. Cases that received type 1 antibiotics had significantly more frequent AAE compared to those that received type 2 antibiotics (adjusted odds ratio [OR], 2.62; 95% confidence interval [CI] 1.15-5.95; P = 0.021). Combined use of type 1 + 2 antibiotics was associated with a significantly higher incidence of AAE compared to the use of type 2 antibiotics alone (adjusted OR, 3.44; 95% CI 1.49-7.93; P = 0.004). Groups with GFR < 60 mL/min/1.73 m2 had significantly higher incidence rates of AAE compared to those with GFRs ≥ 90 mL/min/1.73 m2 among cases that received type 1 + 2 antibiotics. Detection of spike-and-wave or sharp-and-wave patterns on electroencephalogram was significantly more common in the combination therapy group. Combination use of antibiotics was associated with a higher incidence of AAE compared to monotherapy. The incidence of AAE significantly increased as renal function decreased, and epileptiform discharges were more likely to be detected in cases receiving combined antibiotics.
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Affiliation(s)
- Jean Hee Kim
- Department of Neurology, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taewon Kim
- Department of Neurology, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-Ro, Bupyeong-Gu, Incheon, 21431, South Korea.
| | - Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong-Hoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yun Jeong Hong
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eunyae Lim
- Department of Neurology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dae Woong Bae
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Mi Noh
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jieun Lee
- Department of Neurology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Knipe MF, Bush WW, Thomas KE, Williams DC. Periodic discharges in veterinary electroencephalography-A visual review. Front Vet Sci 2023; 10:1037404. [PMID: 36777678 PMCID: PMC9909489 DOI: 10.3389/fvets.2023.1037404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/03/2023] [Indexed: 01/27/2023] Open
Abstract
First described in human EEG over 60 years ago, there are very few examples of periodic discharges in the veterinary literature. They are associated with a wide variety of etiologies, both intracranial and systemic, making interpretation challenging. Whether these patterns are indicative of ictal, interictal, or postictal activity is a matter of debate and may vary depending on the clinical features in an individual patient. Periodic discharges have a repeated waveform occurring at nearly regular intervals, with varying morphology of individual discharges from simple sharp waves or slow waves to more complex events. Amplitudes, frequencies, and morphologies of the discharges can fluctuate, occasionally evolving, or resolving over time. This study presents a visual review of several veterinary cases with periodic discharges on EEG similar to those described in human EEG, and discusses the current known pathophysiology of these discharges.
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Affiliation(s)
- Marguerite F. Knipe
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States,*Correspondence: Marguerite F. Knipe ✉
| | - William W. Bush
- Bush Veterinary Neurology Service, Leesburg, VA, United States
| | | | - D. Colette Williams
- School of Veterinary Medicine, William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, United States
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4
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Lapalme-Remis S. A Cry for Survival? Rhythmic and Periodic EEG Discharges as Treatment Targets Following Cardiac Arrest. Epilepsy Curr 2022; 22:294-296. [PMID: 36285207 PMCID: PMC9549238 DOI: 10.1177/15357597221120486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Treating Rhythmic and Periodic EEG Patterns in Comatose Survivors of Cardiac
Arrest Ruijter BJ, Keijzer HM, Tjepkema-Cloostermans MC, Blans MJ, Beishuizen A, Tromp SC,
Scholten E, Horn J, van Rootselaar AF, Admiraal MM, van den Bergh WM, Elting JJ,
Foudraine NA, Kornips FHM, van Kranen-Mastenbroek VHJM, Rouhl RPW, Thomeer EC,
Moudrous W, Nijhuis FAP, Booij SJ, Hoedemaekers CWE, Doorduin J, Taccone FS, van der
Palen J, van Putten MJAM, Hofmeijer J. N Engl J Med.
2022;386(8):724-734. doi:10.1056/NEJMoa2115998 Background: Whether the treatment of rhythmic and periodic electroencephalographic (EEG)
patterns in comatose survivors of cardiac arrest improves outcomes is uncertain. Methods: We conducted an open-label trial of suppressing rhythmic and periodic EEG patterns
detected on continuous EEG monitoring in comatose survivors of cardiac arrest.
Patients were randomly assigned in a 1:1 ratio to a stepwise strategy of antiseizure
medications to suppress this activity for at least 48 consecutive hours plus
standard care (antiseizure-treatment group) or to standard care alone (control
group); standard care included targeted temperature management in both groups. The
primary outcome was neurologic outcome according to the score on the Cerebral
Performance Category (CPC) scale at 3 months, dichotomized as a good outcome (CPC
score indicating no, mild, or moderate disability) or a poor outcome (CPC score
indicating severe disability, coma, or death). Secondary outcomes were mortality,
length of stay in the intensive care unit (ICU), and duration of mechanical
ventilation. Results: We enrolled 172 patients, with 88 assigned to the antiseizure-treatment group and
84 to the control group. Rhythmic or periodic EEG activity was detected a median of
35 hours after cardiac arrest; 98 of 157 patients (62%) with available data had
myoclonus. Complete suppression of rhythmic and periodic EEG activity for 48
consecutive hours occurred in 49 of 88 patients (56%) in the antiseizure-treatment
group and in 2 of 83 patients (2%) in the control group. At 3 months, 79 of 88
patients (90%) in the antiseizure-treatment group and 77 of 84 patients (92%) in the
control group had a poor outcome (difference, 2 percentage points; 95% confidence
interval, −7 to 11; P = 0.68). Mortality at 3 months was 80% in the
antiseizure-treatment group and 82% in the control group. The mean length of stay in
the ICU and mean duration of mechanical ventilation were slightly longer in the
antiseizure-treatment group than in the control group. Conclusions: In comatose survivors of cardiac arrest, the incidence of a poor neurologic outcome
at 3 months did not differ significantly between a strategy of suppressing rhythmic
and periodic EEG activity with the use of antiseizure medication for at least 48
hours plus standard care and standard care alone.
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5
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Tantillo GB, Jetté N, Gururangan K, Agarwal P, Marcuse L, Singh A, Goldstein J, Kwon CS, Dhamoon MS, Navis A, Nadkarni GN, Charney AW, Young JJ, Blank LJ, Fields M, Yoo JY. Electroencephalography at the height of a pandemic: EEG findings in patients with COVID-19. Clin Neurophysiol 2022; 137:102-112. [PMID: 35305494 PMCID: PMC8901228 DOI: 10.1016/j.clinph.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To characterize continuous video electroencephalogram (VEEG) findings of hospitalized COVID-19 patients. METHODS We performed a retrospective chart review of patients admitted at three New York City hospitals who underwent VEEG at the peak of the COVID-19 pandemic. Demographics, comorbidities, neuroimaging, VEEG indications and findings, treatment, and outcomes were collected. RESULTS Of 93 patients monitored, 77% had severe COVID-19 and 40% died. Acute ischemic or hemorrhagic stroke was present in 26% and 15%, respectively. Most common VEEG indications were encephalopathy/coma (60%) and seizure-like movements (38%). Most common VEEG findings were generalized slowing (97%), generalized attenuation (31%), generalized periodic discharges (17%) and generalized sharp waves (15%). Epileptiform abnormalities were present in 43% and seizures in 8% of patients, all of whom had seizure risk factors. Factors associated with an epileptiform VEEG included increasing age (OR 1.07, p = 0.001) and hepatic/renal failure (OR 2.99, p = 0.03). CONCLUSIONS Most COVID-19 patients who underwent VEEG monitoring had severe COVID-19 and over one-third had acute cerebral injury (e.g., stroke, anoxia). Seizures were uncommon. VEEG findings were nonspecific. SIGNIFICANCE VEEG findings in this cohort of hospitalized COVID-19 patients were those often seen in critical illness. Seizures were uncommon and occurred in the setting of common seizure risk factors.
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Affiliation(s)
- Gabriela B Tantillo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Kapil Gururangan
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parul Agarwal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Lara Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Anuradha Singh
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | | | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Allison Navis
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Girish N Nadkarni
- Icahn School of Medicine at Mount Sinai, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, USA; Mount Sinai COVID-19 Informatics Center, USA
| | - Alexander W Charney
- Icahn School of Medicine at Mount Sinai, USA; Mount Sinai COVID-19 Informatics Center, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, USA
| | - James J Young
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Leah J Blank
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Madeline Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, USA.
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6
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Abstract
PURPOSE Anesthetic agents have been widely used in the treatment of refractory status epilepticus and the medical management of increased intracranial pressure whenever the goal is therapeutic burst suppression. Periodic patterns typically consisting of generalized periodic discharges (GPDs) following emergence from anesthesia have been described in several case reports. However, their clinical significance and in particular whether these patterns are epileptiform remains unclear. METHODS This is a single-center, retrospective, observational study examining EEG patterns following emergence from pharmacologically induced burst suppression. Clinical and EEG data were collected. Patients who developed GPDs following anesthetic wean were compared with those who did not. RESULTS Over 4.5 years, 14 patients developed GPDs related to anesthetic withdrawal. The GPDs had a frequency between 0.5 and 2.5 Hz. Generalized periodic discharges related to anesthetic withdrawal were transient, with a median duration of 40 hours (interquartile range, 24-48 hours). Notably, in all patients, the pattern was stimulus dependent. When compared with a control group of 19 consecutive patients who did not develop a generalized periodic pattern in the context of the anesthetic wean, there was no significant difference in the status epilepticus relapse between the two groups (29% vs. 44%; P = 0.63). Patients in the GPD group were more likely to be on pentobarbital (93% vs. 58%; P = 0.05) and were more likely to have concomitant systemic infection treated with antibiotics compared with the control group (86% vs. 42%; P = 0.02). CONCLUSIONS Generalized periodic patterns are common following the wean of intravenous anesthetics (particularly pentobarbital) and likely represent a transitional encephalopathic state in a subset of patients. Their morphology is distinct and can be differentiated from the reemergence of status epilepticus (if the latter was the indication for anesthetic treatment). Failure to recognize this pattern may lead to prolonged unnecessary treatments if it is mistaken for the emergence of seizure activity. The presence of concomitant systemic infection and associated antibiotic treatment may be risk factors for the development of this pattern.
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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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8
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Husari KS, Kaplan PW. Are Triphasic Waves Different From Generalized Spike-Wave Discharges? J Clin Neurophysiol 2021; 38:e20-e23. [PMID: 34009844 DOI: 10.1097/wnp.0000000000000845] [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: 11/25/2022] Open
Abstract
SUMMARY Generalized periodic discharges with triphasic morphology were previously referred to as triphasic waves but have now been subsumed into the ACNS classification as generalized periodic discharges. Although triphasic waves and generalized spike-wave complexes may resemble each other and hence may be incorrectly identified in comatose critically ill patients, many authors believe that there are different entities, with definable morphologic and clinical differences attributable to each waveform. The occurrence of both patterns in the same patient is extremely rare with only a single prior case report. Here the authors report a patient with typical triphasic waves and generalized spike-wave complexes and highlight the morphologic and EEG differences between the two patterns. The occurrence of both waveforms in the same EEG recording supports the notion of different cerebral generators and pathways, further differentiating rather than merging these morphologies.
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Affiliation(s)
- Khalil S Husari
- Department of Neurology, Johns Hopkins University; Baltimore, Maryland, U.S.A.; and
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University; Baltimore, Maryland, U.S.A.; and
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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Sinkin MV, Talypov AE, Yakovlev AA, Kordonskaya OO, Teplyshova AM, Trifonov IS, Guekht AB, Krylov VV. [Long-term EEG monitoring in patients with acute traumatic brain injury]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:62-67. [PMID: 34184480 DOI: 10.17116/jnevro202112105162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the informativeness of long-term scalp EEG monitoring in patients with acute traumatic brain injury (TBI). MATERIAL AND METHODS The informativity of long-term EEG monitoring (LTM) was performed in 60 patients with acute severe TBI. Odd ratios (OR) of unfavorable outcome and non-convulsive status epilepticus (NCSE) among clinical, neurophysiological and radiological features were calculated. RESULTS EEG features of the unfavorable outcome are: slowing of the dominant background rhythm below q range (OR 3.5, CI 1.2-10.7), absence of frontal-occipital gradient (OR 10.2, CI 1.89-10.12), absence of reactivity (OR 8.75, CI 2.14-35.7), absence of variability (OR 6.25, CI 1.72-22.6) and absence of NREM sleep, stage 2 (OR 5.8, CI 1.79-18.91). Clinical features associated with the unfavorable outcome are: a decrease in GCS score (OR 1.25, CI 1.07-1.47), TBI severity (OR 2.46, CI 1.16-5.18), axial dislocation (OR 4.45, CI 1.08-18.29). ORs for NCSE are significant for the following EEG features: presence of rhythmic and periodic patterns (RPP) (OR 11.92, CI 1.37-103.39), stimulus induced RPP (OR 23.14, CI 2.56-209.34), "plus" modifier (OR 4.11, CI 1.13-14.91) and electrographic evolution (OR 13.05, CI 3.59-47.39). Background rhythm slowing below q range reduces NCSE probability (OR 3.33, CI 1.09-10). CONCLUSION Long-term EEG monitoring is an informative tool for prognosis of outcome and diagnosis of NCSE in patients with severe TBI. The risk of NCSE increases with Marshall score but NCSE is not associated with poor outcome that requires an individual selection of intensive care.
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Affiliation(s)
- M V Sinkin
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia.,Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A E Talypov
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia
| | - A A Yakovlev
- Institute of Higher Nervous Activity and Neurophysiology of the Russian Academy of Sciences, Moscow, Russia.,Soloviev Scientific and Practical Psychoneurological Center, Moscow, Russia
| | - O O Kordonskaya
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia.,Federal Center of Brain and Neurotechnology, Moscow, Russia
| | | | - I S Trifonov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A B Guekht
- Soloviev Scientific and Practical Psychoneurological Center, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - V V Krylov
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia.,Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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10
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Generalized periodic discharges with triphasic morphology: to treat or not to treat? Epileptic Disord 2021; 23:435-436. [PMID: 33926861 DOI: 10.1684/epd.2021.1272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Li F, Huang L, Yan Y, Wang X, Hu Y. A novel nomogram for early prediction of death in severe neurological disease patients with electroencephalographic periodic discharges. Clin Neurophysiol 2021; 132:1304-1311. [PMID: 33867264 DOI: 10.1016/j.clinph.2021.03.002] [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: 11/06/2020] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate death-related factors in patients with electroencephalographic (EEG) periodic discharges (PDs) and to construct a model for death prediction. METHODS This case-control study enrolled a total of 80 severe neurological disease patients with EEG PDs within 72 h of admission to the neuroscience intensive care unit (NICU). According to modified Rankin scale (mRS) scores half a year after discharge, patients were divided into a survival group (<6 points) and a death group (6 points). Their relevant clinical and biochemical indicators as well as EEG characteristics were retrospectively analyzed. Logistic regression analysis was used to identify the risk factors associated with the death of patients with EEG PDs. A death risk prediction model and an individualized nomogram prediction model were constructed, and the prediction performance and concordance of the models were evaluated. RESULTS Multivariate logistic regression analysis showed that the involvement of both gray and white matter in imaging, disappearance of EEG reactivity, occurrence of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs), and an interval time of 0.5-4 s were independent risk factors for death. A regression model was established according to the multivariate logistic regression analysis, and the area under the curve of this model was 0.9135. The accuracy of the model was 87.01%, the sensitivity was 87.17%, and the specificity was 89.17%. A nomogram model was constructed, and a concordance index of 0.914 was obtained after internal validation. CONCLUSION The regression model based on risk factors has high accuracy in predicting the risk of death of patients with EEG PDs. SIGNIFICANCE This model can help clinicians in the early assessment of the prognosis of severe neurological disease patients with EEG PDs.
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Affiliation(s)
- Feng Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, People's Republic of China
| | - Lihong Huang
- Chongqing Medical University, Chongqing 400016, People's Republic of China
| | - Yin Yan
- Department of Neurology, The Ninth People's Hospital of Chongqing, Chongqing 400700, People's Republic of China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, People's Republic of China.
| | - Yida Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, People's Republic of China.
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12
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Miyashiro L, Oliveira DE Paulo C, Twardowschy CA. Presence of generalized periodic discharges and hospital mortality. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:356-360. [PMID: 32401832 DOI: 10.1590/0004-282x20200026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/19/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Generalized periodic discharges (GPDs) are rare patterns that can be found in long-term electroencephalographic monitoring in critical patients. These patterns have been correlated with non-seizure crisis and non-convulsive status epilepticus, associated with poor prognosis. OBJECTIVE To compare the outcome between patients who developed GPDs and patients with other abnormalities in long-term electroencephalographic monitoring. METHODS A retrospective study was performed by analyzing the medical records of 112 patients over 18 years who developed GPDs during long-term electroencephalographic monitoring (12‒16 hours of monitoring) in the intensive care unit of a general hospital, compared with a group that had only nonspecific abnormalities in the monitoring. RESULTS Age and cardiorespiratory arrest (CA) were risk factors for death - OR 1.04 (95% CI 1,02 - 1,07) and p<0.001; OR 3.00 (95% CI 1,01 - 8,92) and p=0.046, respectively. It was not possible to evaluate if GPDs alone were associated with an unfavorable outcome or would be a bias for the development of CA in these patients. However, of the six isolated GPDs cases, 2/3 evolved to death, showing a tendency to worse prognosis. A significant difference (p=0.031) was observed for a worse outcome when comparing the group of 28 patients who presented GPD or CA with the other group which did not present any of these variables; of these 28 patients, 20 (71.4%) died. CONCLUSIONS The presence of post-CA GPDs was associated with worse prognosis, but it was not clear whether these patterns are independent factors of an unfavorable evolution.
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Affiliation(s)
- Larissa Miyashiro
- Pontifícia Universidade Católica do Paraná, Hospital Universitário Cajuru, Curitiba, Paraná, Brazil
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Abstract
PURPOSE Triphasic waves (TWs) have been associated with a host of medication toxicities, and cefepime has emerged recently as a frequently encountered offending agent. This investigation aims to evaluate cefepime-induced encephalopathy and to report the associated clinical, EEG expression with TWs, and the radiologic findings. METHODS A retrospective multicenter observational study examining adult patients with cefepime-induced encephalopathy with generalized periodic discharges on either routine or continuous EEG between January 2014 and January 2020. Clinical, electrographic, and radiologic data were collected. Patients in whom cefepime was not the sole causative factor for their encephalopathy were excluded. RESULTS Twenty-seven patients with cefepime-induced encephalopathy marked by generalized periodic discharges with triphasic morphology were identified at both centers, whereas no patients were presenting with generalized periodic discharges without TWs. Patients had a median age of 63 years (interquartile range, 56-73). Fifty-six percent of the cohort (15 patients) were <65 years of age. Eighteen patients (67%) had either acute or chronic kidney impairment (either acute kidney injury or chronic kidney disease or both), whereas 81% had preexisting white matter disease on brain imaging. Of these, 14 patients (51%) were classified as either moderate or severe. In the majority of the patients, TWs were either state-dependent or stimulus-sensitive, and in one third of them presented only as stimulus-induced pattern. All patients improved with discontinuation of cefepime. CONCLUSIONS Cefepime toxicity should be considered in the differential diagnosis in encephalopathic patients with TWs. The presence of preexisting white matter disease in these patients should heighten the degree of suspicion, especially in younger patients and patients without renal dysfunction.
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Abstract
AbstractContinuous electroencephalogram (cEEG) has become an indispensable technique in the management of critically ill patients for early detection and treatment of non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE). It has also brought about a renaissance in a wide range of rhythmic and periodic patterns with heterogeneous frequency and morphology. These patterns share the rhythmic and sharp appearances of electrographic seizures, but often lack the necessary frequency, spatiotemporal evolution and clinical accompaniments to meet the definitive criteria for ictal patterns. They may be associated with cerebral metabolic crisis and neuronal injury, therefore not clearly interictal either, but lie along an intervening spectrum referred to as ictal-interictal continuum (IIC). Generally speaking, rhythmic and periodic patterns are categorized as interictal patterns when occurring at a rate of <1Hz, and are categorized as NCS and NCSE when occurring at a rate of >2.5 Hz with spatiotemporal evolution. As such, IIC commonly includes the rhythmic and periodic patterns occurring at a rate of 1–2.5 Hz without spatiotemporal evolution and clinical correlates. Currently there are no evidence-based guidelines on when and if to treat patients with IIC patterns, and particularly how aggressively to treat, presenting a challenging electrophysiological and clinical conundrum. In practice, a diagnostic trial with preferably a non-sedative anti-seizure medication (ASM) can be considered with the end point being both clinical and electrographic improvement. When available and necessary, correlation of IIC with biomarkers of neuronal injury, such as neuronal specific enolase (NSE), neuroimaging, depth electrode recording, cerebral microdialysis and oxygen measurement, can be assessed for the consideration of ASM treatment. Here we review the recent advancements in their clinical significance, risk stratification and treatment algorithm.
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Punia V, Zawar I, Briskin I, Burgess R, Newey CR, Hantus S. Determinants and outcome of repeat continuous electroencephalogram monitoring-A case-control study. Epilepsia Open 2019; 4:572-580. [PMID: 31819913 PMCID: PMC6885659 DOI: 10.1002/epi4.12361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/28/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE A retrospective, single-center study to analyze the determinants of a repeat continuous EEG (cEEG) monitoring during hospitalization and its outcomes using a matched case-control study design. METHODS Adults with a repeat cEEG session (cases) were matched by age (±3 years), gender, and mental status to patients with a single cEEG (controls) during hospitalization. Several clinical and EEG characteristics were analyzed to identify predictors of repeat cEEG. Repeat cEEG outcomes were analyzed based on its yield of electrographic seizure. We investigated the predictors of finding increased epileptic potential (degree of association with electrographic seizures) on the repeat cEEG, a marker for possible anti-epileptic drugs (AEDs) management change. RESULTS A total of 213 (8.6% of all unique cEEG patients) cases were included. A multivariable conditional logistic regression model comparing cases and controls showed that the presence of acute brain insult [odds ratio (OR) = 3.36, 95% CI = 1.26-8.94, P = .015], longer hospital admission (OR = 1.11, 95% CI = 1.07-1.15, P < .001) and being on AEDs at the end of index cEEG (OR = 4.0, 95% CI = 1.8-8.87, P < .001) was determinants of a repeat cEEG. Among cases, 17 (8%) had electrographic seizures on repeat cEEG. Increased epileptic potential on repeat cEEG was noted in 34 (16%) cases. The latter is associated with change in etiology after the index cEEG (P = .03) and duration of repeat cEEG (P = .003) based on multivariable logistic regression model. AEDs were changed in 46 (21.6%) patients based on repeat cEEG findings. SIGNIFICANCE Repeat cEEG is not an uncommon practice. It leads to the diagnosis of electrographic seizures in a significant percentage of patients. With the potential of impacting AED management in 16%-21% patients, it should be considered in high-risk patients suffering acute brain insults undergoing prolonged hospitalization.
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Affiliation(s)
- Vineet Punia
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhio
| | - Ifrah Zawar
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhio
| | - Isaac Briskin
- Department of Quantitative Health SciencesLerner Research InstituteClevelandOhio
| | - Richard Burgess
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhio
| | - Christopher R. Newey
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhio
- Neurocritical careNeurological InstituteCleveland ClinicClevelandOhio
| | - Stephen Hantus
- Epilepsy CenterNeurological InstituteCleveland ClinicClevelandOhio
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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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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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