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Sansevere AJ, Keenan JS, Pickup E, Conley C, Staso K, Harrar DB. Ictal-Interictal Continuum in the Pediatric Intensive Care Unit. Neurocrit Care 2024:10.1007/s12028-024-01978-4. [PMID: 38671312 DOI: 10.1007/s12028-024-01978-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 03/08/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The ictal-interictal continuum (IIC) consists of several electroencephalogram (EEG) patterns that are common in critically ill adults. Studies focused on the IIC are limited in critically ill children and have focused primarily on associations with electrographic seizures (ESs). We report the incidence of the IIC in the pediatric intensive care unit (PICU). We then compare IIC patterns to rhythmic and periodic patterns (RPP) not meeting IIC criteria looking for associations with acute cerebral abnormalities, ES, and in-hospital mortality. METHODS This was a retrospective review of prospectively collected data for patients admitted to the PICU at Children's National Hospital from July 2021 to January 2023 with continuous EEG. We excluded patients with known epilepsy and cerebral injury prior to presentation. All patients were screened for RPP. The American Clinical Neurophysiology Society standardized Critical Care EEG terminology for the IIC was applied to each RPP. Associations between IIC and RPP not meeting IIC criteria, with clinical and EEG variables, were calculated using odds ratios (ORs). RESULTS Of 201 patients, 21% (42/201) had RPP and 12% (24/201) met IIC criteria. Among patients with an IIC pattern, the median age was 3.4 years (interquartile range (IQR) 0.6-12 years). Sixty-seven percent (16/24) of patients met a single IIC criterion, whereas the remainder met two criteria. ESs were identified in 83% (20/24) of patients and cerebral injury was identified in 96% (23/24) of patients with IIC patterns. When comparing patients with IIC patterns with those with RPP not qualifying as an IIC pattern, both patterns were associated with acute cerebral abnormalities (IIC OR 26 [95% confidence interval {CI} 3.4-197], p = 0.0016 vs. RPP OR 3.5 [95% CI 1.1-11], p = 0.03), however, only the IIC was associated with ES (OR 121 [95% CI 33-451], p < 0.0001) versus RPP (OR 1.3 [0.4-5], p = 0.7). CONCLUSIONS Rhythmic and periodic patterns and subsequently the IIC are commonly seen in the PICU and carry a high association with cerebral injury. Additionally, the IIC, seen in more than 10% of critically ill children, is associated with ES. The independent impact of RPP and IIC patterns on secondary brain injury and need for treatment of these patterns independent of ES requires further study.
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Affiliation(s)
- Arnold J Sansevere
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Julia S Keenan
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Elizabeth Pickup
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Caroline Conley
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
- Department of Critical Care Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Katelyn Staso
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
- Department of Critical Care Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Dana B Harrar
- Department of Neurology/Division of Epilepsy and Clinical Neurophysiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Anadure R, Goel J, Saxena R, Gupta S, Vidhale T. A study on the clinical and electrographic profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Med J Armed Forces India 2023; 79:292-299. [PMID: 37193513 PMCID: PMC10182287 DOI: 10.1016/j.mjafi.2021.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/27/2021] [Indexed: 10/20/2022] Open
Abstract
Background Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3-8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value < 0.05). The EEG recordings of patients with NCSE showed dynamicity with fluctuating rhythms and ictal-EEG patterns associated with spatiotemporal evolution. All twelve cases showed reversal of EEG changes with AED administration. In 5 out of 12, transient improvement in GCS (>2 points) after administration of AED' was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.
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Affiliation(s)
- R.K. Anadure
- Senior Advisor & Head (Neurology), Army Hospital (R&R), New Delhi, India
| | - J. Goel
- Classified Specialist (Medicine & Neurology), Command Hospital (Air Force), Bengaluru, India
| | - Rajeev Saxena
- Senior Advisor (Medicine & Neurology), Command Hospital (WC), C/o 56 APO, India
| | - Salil Gupta
- Consultant (Medicine & Neurology), Command Hospital (Air Force), Bengaluru, India
| | - Tushar Vidhale
- Senior Resident (Medicine), Command Hospital (Air Force), Bengaluru, India
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3
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Holla SK, Krishnamurthy PV, Subramaniam T, Dhakar MB, Struck AF. Electrographic Seizures in the Critically Ill. Neurol Clin 2022; 40:907-925. [PMID: 36270698 PMCID: PMC10508310 DOI: 10.1016/j.ncl.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Identifying and treating critically ill patients with seizures can be challenging. In this article, the authors review the available data on patient populations at risk, seizure prognostication with tools such as 2HELPS2B, electrographic seizures and the various ictal-interictal continuum patterns with their latest definitions and associated risks, ancillary testing such as imaging studies, serum biomarkers, and invasive multimodal monitoring. They also illustrate 5 different patient scenarios, their treatment and outcomes, and propose recommendations for targeted treatment of electrographic seizures in critically ill patients.
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Affiliation(s)
- Smitha K Holla
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA.
| | | | - Thanujaa Subramaniam
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 15 York Street, Building LLCI, 10th Floor, Suite 1003 New Haven, CT 06520, USA
| | - Monica B Dhakar
- Department of Neurology, The Warren Alpert Medical School of Brown University, 593 Eddy St, APC 5, Providence, RI 02903, USA
| | - Aaron F Struck
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA; William S Middleton Veterans Hospital, Madison WI, USA
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4
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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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5
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Romoli M, Merli E, Galluzzo S, Muccioli L, Testoni S, Zaniboni A, Contardi S, Simonetti L, Tinuper P, Zini A. Hyperperfusion Tmax mapping for nonconvulsive status epilepticus in the acute setting: A pilot case-control study. Epilepsia 2022; 63:2534-2542. [PMID: 35793391 PMCID: PMC9796764 DOI: 10.1111/epi.17359] [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: 04/07/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Nonconvulsive status epilepticus (NCSE) is misdiagnosed in >50% of cases in the emergency department. Computed tomographic perfusion (CTP) has been implemented in the hyperacute setting to detect seizure-induced hyperperfusion. However, the diagnostic value of CTP is limited by the lack of thresholds for hyperperfusion and high interrater variability. This pilot case-control study aims at identifying the diagnostic value of reverse Tmax (rTmax) in differentiating NCSE from acute ischemic stroke in the hyperacute setting. METHODS We enrolled patients with NCSE (Salzburg criteria-based diagnosis) and stroke cases 1:1 matched for clinical features and time of presentation. CTP standard maps (mean transit time [MTT]-cerebral blood volume-cerebral blood flow [CBF]) and rTmax maps were elaborated and rated by two experts in CTP blinded to the final diagnosis. Hyperperfusion was adjudicated for standard CTP maps as an increase in CBF and a decrease in MTT, and for rTmax as the presence of a black area on 3-, 2-, and 1-s threshold maps. Cronbach alpha was used for interrater agreement; receiver operating curve analysis was run to measure accuracy with area under the curve. RESULTS Overall, 34 patients were included (17 NCSE, 17 stroke; time from onset to imaging = 2 h for both groups). People with NCSE were older and more frequently had a history of epilepsy. NCSE patients had hyperperfusion on rTmax maps in 11 of 17 cases versus zero of 17 in stroke. Intra- and interrater reliability was higher for rTmax than for standard CTP maps (κ = 1 vs. κ = .6). rTmax was 82% (95%CI = 67-97%) accurate in predicting NCSE versus stroke in the hyperacute setting. Agreement between neuroimaging and electroencephalography (EEG) was limited at a hemispheric level for standard CTP maps, whereas rTMax had agreement with EEG largely reaching the sublobar level. SIGNIFICANCE rTmax mapping might represent a reliable tool to spot NCSE-induced hyperperfusion with a threshold-based reproducible approach. Further studies are needed for validation and implementation in the differential diagnosis of focal neurological deficit in the hyperacute setting.
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Affiliation(s)
| | - Elena Merli
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Simone Galluzzo
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - Stefania Testoni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Anna Zaniboni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Sara Contardi
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Luigi Simonetti
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly,IRCCS Istituto delle ScienzeNeurologiche di BolognaFull Member of the ERN EpiCAREBolognaItaly
| | - Andrea Zini
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
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Factors associated with the use of anesthetic drug infusion in patients with status epilepticus and their relation to outcome: a prospective study. Acta Neurol Belg 2022; 122:377-384. [PMID: 33606198 DOI: 10.1007/s13760-021-01625-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/02/2021] [Indexed: 01/28/2023]
Abstract
Status epilepticus (SE) is one of the most dreadful neurological emergencies; unfortunately, studies targeting SE are still inadequate. This study aims to identify factors associated with the use of CIVAD in patients presenting with status epilepticus and detect those impact the clinical outcome. A prospective study involving 144 episodes of SE in 144 patients. Patients were categorized according to whether or not they received CIVAD. Subjects underwent clinical assessment, brain imaging, and EEG. The consciousness level was assessed using the Glasgow coma scale (GCS) and the Full outline of responsiveness (FOUR) scale. SE severity score (STESS) and Epidemiology-based mortality score (EMSE) were used as scales for outcome prediction. Continuous IV anesthetic drug infusion was initiated in 36% of patients (+ CIVAD). Such groups showed a significantly worse initial level of consciousness (< 0.001), an unstable course of seizure evolution (0.009), and all of them showed abnormal EEG patterns. A significantly higher number of patients (+ CIVAD) developed complications (< 0.001), had higher outcome prediction scores (< 0.001), and mortality rates (< 0.001) compared to those who did not need CIVAD (- CIVAD). Mortality was associated with acute symptomatic etiology and higher total doses of propofol. Among the study population, mortality among patients who received CIVAD was associated with acute symptomatic SE and prolonged propofol infusion rather than any clinical parameters or predictor scores.
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Trinka E, Leitinger M. Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus. Continuum (Minneap Minn) 2022; 28:559-602. [PMID: 35393970 DOI: 10.1212/con.0000000000001103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Status epilepticus is a serious condition caused by disorders and diseases that affect the central nervous system. In status epilepticus, hypersynchronous epileptic activity lasts longer than the usual duration of isolated self-limited seizures (time t1), which causes neuronal damage or alteration of neuronal networks at a certain time point (time t2), depending on the type of and duration of status epilepticus. The successful management of status epilepticus includes both the early termination of seizure activity and the earliest possible identification of a causative etiology, which may require independent acute treatment. In nonconvulsive status epilepticus, patients present only with subtle clinical signs or even without any visible clinical manifestations. In these cases, EEG allows for the assessment of cerebral function and identification of patterns in need of urgent treatment. RECENT FINDINGS In 2015, the International League Against Epilepsy proposed a new definition and classification of status epilepticus, encompassing four axes: symptomatology, etiology, EEG, and age. Various validation studies determined the practical usefulness of EEG criteria to identify nonconvulsive status epilepticus. The American Clinical Neurophysiology Society has incorporated these criteria into their most recent critical care EEG terminology in 2021. Etiology, age, symptomatology, and the metabolic demand associated with an increasing duration of status epilepticus are the most important determinants of prognosis. The consequences of status epilepticus can be visualized in vivo by MRI studies. SUMMARY The current knowledge about status epilepticus allows for a more reliable diagnosis, earlier treatment, and improved cerebral imaging of its consequences. Outcome prediction is a soft tool for estimating the need for intensive care resources.
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FIERAIN A, GASPARD N, LEJEUNE N, EL TAHRY R, SPEYBROECK N, DERMAUW V, FERRAO SANTOS S. Beware of nonconvulsive seizures in prolonged disorders of consciousness: long-term EEG monitoring is the key. Clin Neurophysiol 2022; 136:228-234. [DOI: 10.1016/j.clinph.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022]
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9
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Othman AS, Abd-Allah F. Non-Convulsive Status Epilepticus (NCSE) in ICU: Bedside Usefulness of TCD in Comatose Patient Diagnosis. When the EEG Is Too Far. NEUROSONOLOGY IN CRITICAL CARE 2022:753-762. [DOI: 10.1007/978-3-030-81419-9_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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10
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Muñoz‐Vendrell A, Sala‐Padró J, Jaraba S, Reynés‐Llompart G, Veciana M, Mora J, Falip M. Functional neuroimaging in nonepileptiform electroencephalographic patterns in status epilepticus. Acta Neurol Scand 2021; 144:687-694. [PMID: 34390250 DOI: 10.1111/ane.13515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The diagnosis of nonconvulsive status epilepticus (NCSE) in patients with nonepileptiform EEG patterns remains a challenge. OBJECTIVE To evaluate the usefulness of single photon emission computerized tomography (SPECT) and its quantification (QtSPECT) in the diagnosis of NCSE. METHODS We retrospectively reviewed patients admitted with clinical suspicion of NCSE who underwent an HMPAO-SPECT simultaneously with scalp EEG showing nonepileptiform patterns, in a 5-year period. After a complete diagnostic workup, treatment, and clinical evolution, disregarding the SPECT results, patients were classified into confirmed NCSE (n = 11) and non-NCSE (n = 8). Then, we compared the EEG and SPECT results in both groups. RESULTS Lateralized rhythmic delta activity (LRDA) was predominant in the NCSE group (45.4%, p = .045), while lateralized irregular slowing was observed equally in both groups. Patients with NCSE showed significant hyperperfusion compared with non-NCSE patients (p = .026). QtSPECT correctly classified 91% of patients in NCSE and 75% patients with non-NCSE (p = .006). CONCLUSIONS Regional cerebral blood flow measured with SPECT could be useful in the diagnosis of NCSE in cases of an EEG pattern with lateralized slow activity and high clinical suspicion.
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Affiliation(s)
- Albert Muñoz‐Vendrell
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Jacint Sala‐Padró
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Sonia Jaraba
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
- Neurology Department Hospital de Viladecans Viladecans Barcelona Spain
| | - Gabriel Reynés‐Llompart
- Medical Physics Department Institut Català d’Oncologia, L’Hospitalet de Llobregat Barcelona Spain
- Image Diagnostic Institute (IDI) Nuclear Medicine Department SPECT Unit Hospital Universitari de Bellvitge Image Diagnostic Institute, L’Hospitalet de Llobregat Barcelona Spain
| | - Misericòrdia Veciana
- Neurology Service Neurophysiology Department Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
| | - Jaume Mora
- Image Diagnostic Institute (IDI) Nuclear Medicine Department SPECT Unit Hospital Universitari de Bellvitge Image Diagnostic Institute, L’Hospitalet de Llobregat Barcelona Spain
| | - Mercè Falip
- Neurology Service Epilepsy Unit Hospital Universitari de Bellvitge‐IDIBELL Universitat de Barcelona, L’Hospitalet de Llobregat Barcelona Spain
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11
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Othman AS, El‐Tamawy MS, Amer H, Kishk NA, Nawito AM, Shaker E, Basheer MA, Alieldin N, Magdy R. Characteristics and outcome in an Egyptian Cohort with status epilepticus. Acta Neurol Scand 2021; 144:375-382. [PMID: 34042176 DOI: 10.1111/ane.13478] [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: 12/22/2020] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Status epilepticus (SE) is an important cause of mortality worldwide. Information regarding associations of mortality outcome in Egypt is limited. The main objective of this study was to describe the clinical characteristics and factors associated with mortality of patients with SE admitted to Cairo University Hospitals. METHODS A prospective observational hospital-based study was conducted from January 2017 to June 2018. Patients with SE aged ≥12 years old were followed with documentation of outcome on discharge as survival versus death. RESULTS The study cohort included 144 SE patients. The majority of episodes (96.5%) were with prominent motor features, while nonconvulsive SE occurred in 3.5%. There was a clear semiology evolution in 22.9% of episodes, 56.3% had unchanging semiology (e.g., just convulsive or just nonconvulsive) and the semiology evolution could not be discerned in 20.8%. In relation to treatment, the majority of cases were responsive (46.5%), whereas 43.1% were refractory and only 10.4% were super-refractory SE. Apart from seven patients who were referred to other hospitals, 99 patients survived whereas 38 (26.4%) died. After regression analysis, only absence of a history of epilepsy, semiology evolution and mechanical ventilator use were associated with mortality increasing its odds by 3.7, 5, 111 times, respectively. CONCLUSION Absence of a history of epilepsy, SE semiology evolution, and mechanical ventilator use was found to be associated with mortality outcome among Egyptian patients with SE.
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Affiliation(s)
- Alshimaa S. Othman
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Mohamed S. El‐Tamawy
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Hanan Amer
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Nirmeen A. Kishk
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Amani M. Nawito
- Department of Neurophysiology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Ehab Shaker
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Mye A. Basheer
- Department of Neurophysiology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Nelly Alieldin
- Department of Cancer Epidemiology National Cancer Institute Cairo University Cairo Egypt
| | - Rehab Magdy
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
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12
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Lattanzi S, Giovannini G, Brigo F, Orlandi N, Trinka E, Meletti S. Clinical phenotypes within nonconvulsive status epilepticus. Epilepsia 2021; 62:e129-e134. [PMID: 34244997 PMCID: PMC8456934 DOI: 10.1111/epi.16999] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 01/03/2023]
Abstract
The study aimed to identify distinct phenotypes within nonconvulsive status epilepticus (NCSE). Consecutive episodes of NCSE in patients at least 14 years old were included. The level of consciousness was assessed through the Glasgow Coma Scale (GCS). Etiology of NCSE was defined as symptomatic (acute, remote, progressive) or unknown. Electroencephalographic (EEG) recordings were searched for lateralized periodic discharges (LPDs), generalized sharply and/or triphasic periodic potentials (GPDs), and spontaneous burst suppression (BS). According to treatment response, NCSE was classified as responsive, refractory, or superrefractory. Average linkage hierarchical cluster analysis was performed with Pearson correlation as similarity measure. Two hundred twenty‐nine episodes of NCSE were included. Three clusters were identified. The first cluster linked GCS score 3–8, presence of spontaneous BS on EEG, acute symptomatic etiology, and treatment superrefractoriness. The second cluster gathered GCS score 9–12, presence of LPDs or GPDs on EEG, unknown etiology, and treatment refractoriness. The third cluster associated GCS score 13–15, absence of LPDs, GPDs, and spontaneous BS on EEG, and progressive and remote symptomatic etiology with treatment responsiveness. Phenotyping the heterogeneity of NCSE into electroclinical clusters can contribute to understanding correlations between pathologic and clinical domains, assessing the intrinsic severity of NCSE episodes, and estimating the likelihood of treatment responsiveness.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Giada Giovannini
- Neurology Unit, Baggiovara Civil Hospital, AOU Modena, Modena, Italy.,PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine, and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Niccolò Orlandi
- Neurology Unit, Baggiovara Civil Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Stefano Meletti
- Neurology Unit, Baggiovara Civil Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Amorim E, McGraw CM, Westover MB. A Theoretical Paradigm for Evaluating Risk-Benefit of Status Epilepticus Treatment. J Clin Neurophysiol 2020; 37:385-392. [PMID: 32890059 DOI: 10.1097/wnp.0000000000000753] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aggressive treatment of status epilepticus with anesthetic drugs can provide rapid seizure control, but it might lead to serious medical complications and worse outcomes. Using a decision analysis approach, this concise review provides a framework for individualized decision making about aggressive and nonaggressive treatment in status epilepticus. The authors propose and review the most relevant parameters guiding the risk-benefit analysis of treatment aggressiveness in status epilepticus and present real-world-based case examples to illustrate how these tools could be used at the bedside and serve to guide future research in refractory status epilepticus treatment.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, California, U.S.A.,Neurology Service, Zuckerberg San Francisco General Hospital, San Francisco, California, U.S.A.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts, U.S.A
| | - Chris M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
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Kamousi B, Karunakaran S, Gururangan K, Markert M, Decker B, Khankhanian P, Mainardi L, Quinn J, Woo R, Parvizi J. Monitoring the Burden of Seizures and Highly Epileptiform Patterns in Critical Care with a Novel Machine Learning Method. Neurocrit Care 2020; 34:908-917. [PMID: 33025543 PMCID: PMC8021593 DOI: 10.1007/s12028-020-01120-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Current electroencephalography (EEG) practice relies on interpretation by expert neurologists, which introduces diagnostic and therapeutic delays that can impact patients' clinical outcomes. As EEG practice expands, these experts are becoming increasingly limited resources. A highly sensitive and specific automated seizure detection system would streamline practice and expedite appropriate management for patients with possible nonconvulsive seizures. We aimed to test the performance of a recently FDA-cleared machine learning method (Claritγ, Ceribell Inc.) that measures the burden of seizure activity in real time and generates bedside alerts for possible status epilepticus (SE). METHODS We retrospectively identified adult patients (n = 353) who underwent evaluation of possible seizures with Rapid Response EEG system (Rapid-EEG, Ceribell Inc.). Automated detection of seizure activity and seizure burden throughout a recording (calculated as the percentage of ten-second epochs with seizure activity in any 5-min EEG segment) was performed with Claritγ, and various thresholds of seizure burden were tested (≥ 10% indicating ≥ 30 s of seizure activity in the last 5 min, ≥ 50% indicating ≥ 2.5 min of seizure activity, and ≥ 90% indicating ≥ 4.5 min of seizure activity and triggering a SE alert). The sensitivity and specificity of Claritγ's real-time seizure burden measurements and SE alerts were compared to the majority consensus of at least two expert neurologists. RESULTS Majority consensus of neurologists labeled the 353 EEGs as normal or slow activity (n = 249), highly epileptiform patterns (HEP, n = 87), or seizures [n = 17, nine longer than 5 min (e.g., SE), and eight shorter than 5 min]. The algorithm generated a SE alert (≥ 90% seizure burden) with 100% sensitivity and 93% specificity. The sensitivity and specificity of various thresholds for seizure burden during EEG recordings for detecting patients with seizures were 100% and 82% for ≥ 50% seizure burden and 88% and 60% for ≥ 10% seizure burden. Of the 179 EEG recordings in which the algorithm detected no seizures, seizures were identified by the expert reviewers in only two cases, indicating a negative predictive value of 99%. DISCUSSION Claritγ detected SE events with high sensitivity and specificity, and it demonstrated a high negative predictive value for distinguishing nonepileptiform activity from seizure and highly epileptiform activity. CONCLUSIONS Ruling out seizures accurately in a large proportion of cases can help prevent unnecessary or aggressive over-treatment in critical care settings, where empiric treatment with antiseizure medications is currently prevalent. Claritγ's high sensitivity for SE and high negative predictive value for cases without epileptiform activity make it a useful tool for triaging treatment and the need for urgent neurological consultation.
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Affiliation(s)
- Baharan Kamousi
- Ceribell Inc., 2483 Old Middlefield Way, Suite 120, Mountain View, CA, USA
| | | | - Kapil Gururangan
- Department of Neurology, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew Markert
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Barbara Decker
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pouya Khankhanian
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Mainardi
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James Quinn
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Raymond Woo
- Ceribell Inc., 2483 Old Middlefield Way, Suite 120, Mountain View, CA, USA
| | - Josef Parvizi
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Grippo A, Amantini A. Continuous EEG on the intensive care unit: Terminology standardization of spectrogram patterns will improve the clinical utility of quantitative EEG. Clin Neurophysiol 2020; 131:2281-2283. [DOI: 10.1016/j.clinph.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022]
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Current Knowledge and Challenges in Status Epilepticus. J Clin Neurophysiol 2020; 37:373-374. [DOI: 10.1097/wnp.0000000000000733] [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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Kapinos G, Desai MJ, Weiss SA, Valsamis HA. Biochemical underpinning of Lateralized Periodic Discharges: Regional glutamate overload? Epilepsy Res 2020; 167:106442. [PMID: 32916643 DOI: 10.1016/j.eplepsyres.2020.106442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Gregory Kapinos
- Departments of Neurology, Neurosurgery & Emergency Medicine, New York City Health + Hospitals / Kings County, Brooklyn, NY, United States; Department of Neurology, State University of New York Downstate Health Sciences University College of Medicine, Brooklyn, NY, United States.
| | - Masoom J Desai
- Division of Critical Care Neurology and Division of Epilepsy & Neurophysiology, Department of Neurology, University of Oklahoma Health Science Center, United States
| | - Shennan A Weiss
- Department of Neurology, Brookdale Hospital Medical Center, Brooklyn, NY, United States
| | - Helen A Valsamis
- Department of Neurology, New York City Health + Hospitals / Kings County, Brooklyn, NY, United States; Department of Neurology, State University of New York Downstate Medical Center, Brooklyn, NY, United States
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Othman AS, Meletti S, Giovannini G. The EEG diagnosis of NCSE: Concordance between clinical practice and Salzburg Criteria for NCSE. Seizure 2020; 79:1-7. [DOI: 10.1016/j.seizure.2020.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022] Open
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Zafar SF, Subramaniam T, Osman G, Herlopian A, Struck AF. Electrographic seizures and ictal-interictal continuum (IIC) patterns in critically ill patients. Epilepsy Behav 2020; 106:107037. [PMID: 32222672 DOI: 10.1016/j.yebeh.2020.107037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/07/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Critical care long-term continuous electroencephalogram (cEEG) monitoring has expanded dramatically in the last several decades spurned by technological advances in EEG digitalization and several key clinical findings: 1-Seizures are relatively common in the critically ill-large recent observational studies suggest that around 20% of critically ill patients placed on cEEG have seizures. 2-The majority (~75%) of patients who have seizures have exclusively "electrographic seizures", that is, they have no overt ictal clinical signs. Along with the discovery of the unexpectedly high incidence of seizures was the high prevalence of EEG patterns that share some common features with archetypical electrographic seizures but are not uniformly considered to be "ictal". These EEG patterns include lateralized periodic discharges (LPDs) and generalized periodic discharges (GPDs)-patterns that at times exhibit ictal-like behavior and at other times behave more like an interictal finding. Dr. Hirsch and colleagues proposed a conceptual framework to describe this spectrum of patterns called the ictal-interictal continuum (IIC). In the following years, investigators began to answer some of the key pragmatic clinical concerns such as which patients are at risk of seizures and what is the optimal duration of cEEG use. At the same time, investigators have begun probing the core questions for critical care EEG-what is the underlying pathophysiology of these patterns, at what point do these patterns cause secondary brain injury, what are the optimal treatment strategies, and how do these patterns affect clinical outcomes such as neurological disability and the development of epilepsy. In this review, we cover recent advancements in both practical concerns regarding cEEG use, current treatment strategies, and review the evidence associating IIC/seizures with poor clinical outcomes.
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Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States of America
| | - Thanujaa Subramaniam
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States of America
| | - Aline Herlopian
- Department of Neurology, Yale University, New Haven, CT, United States of America
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, United States of America.
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Lybeck A, Cronberg T, Borgquist O, Düring JP, Mattiasson G, Piros D, Backman S, Friberg H, Westhall E. Bedside interpretation of simplified continuous EEG after cardiac arrest. Acta Anaesthesiol Scand 2020; 64:85-92. [PMID: 31465539 DOI: 10.1111/aas.13466] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Continuous EEG-monitoring (cEEG) in the ICU is recommended to assess prognosis and detect seizures after cardiac arrest but implementation is often limited by the lack of EEG-technicians and experts. The aim of the study was to assess ICU physicians ability to perform preliminary interpretations of a simplified cEEG in the post cardiac arrest setting. METHODS Five ICU physicians received training in interpretation of simplified cEEG - total training duration 1 day. The ICU physicians then interpreted 71 simplified cEEG recordings from 37 comatose survivors of cardiac arrest. The cEEG included amplitude-integrated EEG trends and two channels with original EEG-signals. Basic EEG background patterns and presence of epileptiform discharges or seizure activity were assessed on 5-grade rank-ordered scales based on standardized EEG terminology. An EEG-expert was used as reference. RESULTS There was substantial agreement (κ 0.69) for EEG background patterns and moderate agreement (κ 0.43) for epileptiform discharges between ICU physicians and the EEG-expert. Sensitivity for detecting seizure activity by ICU physicians was limited (50%), but with high specificity (87%). CONCLUSIONS After cardiac arrest, preliminary bedside interpretations of simplified cEEGs by trained ICU physicians may allow earlier detection of clinically relevant cEEG changes, prompting changes in patient management as well as additional evaluation by an EEG-expert. This strategy requires awareness of limitations of both the simplified electrode montage and the cEEG interpretations performed by ICU physicians. cEEG evaluation by an expert should not be delayed.
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Affiliation(s)
- Anna Lybeck
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Neurology Lund Sweden
| | - Ola Borgquist
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Joachim Pascal Düring
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Gustav Mattiasson
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - David Piros
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Sofia Backman
- Department of Clinical Sciences Lund Lund UniversitySkane University HospitalClinical Neurophysiology Lund Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund Lund UniversitySkane University Hospital, Anesthesia and Intensive Care Lund Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund Lund UniversitySkane University HospitalClinical Neurophysiology Lund Sweden
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Nichol G, Polderman KH, Friberg H, Kurz M, Kapinos G. Perspectives on Temperature Management. Ther Hypothermia Temp Manag 2018; 8:188-194. [DOI: 10.1089/ther.2018.29052.gjn] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Division of Internal Medicine, Seattle, Washington
| | - Kees H. Polderman
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Hans Friberg
- Department of Emergency Medicine, Skane University Hospital, Lund University, Lund, Sweden
| | - Michael Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gregory Kapinos
- Departments of Neurology, Neurosurgery and Emergency Medicine, Kings County Hospital/SUNY Downstate College of Medicine, Brooklyn, New York
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Sinkin MV, Krylov VV. Rhythmic and periodic EEG patterns. Classification and clinical significance. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:9-20. [DOI: 10.17116/jnevro20181181029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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