1
|
Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [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] [Received: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
Collapse
Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
| |
Collapse
|
2
|
Liu G, Wang Y, Tian F, Chen W, Cui L, Jiang M, Zhang Y, Gao K, Su Y, Wang H. Quantitative EEG reactivity induced by electrical stimulation predicts good outcome in comatose patients after cardiac arrest. Ann Intensive Care 2024; 14:99. [PMID: 38935167 PMCID: PMC11211292 DOI: 10.1186/s13613-024-01339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND EEG reactivity is a predictor for neurological outcome in comatose patients after cardiac arrest (CA); however, its application is limited by variability in stimulus types and visual assessment. We aimed to evaluate the prognostic value of the quantitative analysis of EEG reactivity induced by standardized electrical stimulation and for early prognostication in this population. METHODS This prospective observational study recruited post-CA comatose patients in Xuanwu Hospital, Capital Medical University (Beijing, China) between January 2016 and June 2023. EEG reactivity to electrical or traditional pain stimulation was randomly performed via visual and quantitative analysis. Neurological outcome within 6 months was dichotomized as good (Cerebral Performance Categories, CPC 1-2) or poor (CPC 3-5). RESULTS Fifty-eight post-CA comatose patients were admitted, and 52 patients were included in the final analysis, of which 19 (36.5%) had good outcomes. EEG reactivity induced with the electrical stimulation had superior performance to the traditional pain stimulation for good outcome prediction (quantitative analysis: AUC 0.932 vs. 0.849, p = 0.048). When using the electrical stimulation, the AUC of EEG reactivity to predict good outcome by visual analysis was 0.838, increasing to 0.932 by quantitative analysis (p = 0.039). Comparing to the traditional pain stimulation by visual analysis, the AUC of EEG reactivity for good prognostication by the electrical stimulation with quantitative analysis was significantly improved (0.932 vs. 0.770, p = 0.004). CONCLUSIONS EEG reactivity induced by the standardized electrical stimulation in combination with quantitative analysis is a promising formula for post-CA comatose patients, with increased predictive accuracy.
Collapse
Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Mengdi Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Keming Gao
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
| | - Hongxing Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
| |
Collapse
|
3
|
Mahajan C, Prabhakar H, Rass V, McNett M, Kapoor I, Helbok R, Zirpe K. A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey. Neurocrit Care 2024; 40:941-952. [PMID: 37821721 DOI: 10.1007/s12028-023-01852-9] [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: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. METHODS This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. RESULTS The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). CONCLUSIONS Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.
Collapse
Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Verena Rass
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Kapil Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
| |
Collapse
|
4
|
Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
5
|
Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Collapse
|
7
|
Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| |
Collapse
|
8
|
Admiraal MM, van Rootselaar A, Hofmeijer J, Hoedemaekers CWE, van Kaam CR, Keijzer HM, van Putten MJAM, Schultz MJ, Horn J. Electroencephalographic reactivity as predictor of neurological outcome in postanoxic coma: A multicenter prospective cohort study. Ann Neurol 2019; 86:17-27. [PMID: 31124174 PMCID: PMC6618107 DOI: 10.1002/ana.25507] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
Abstract
Objective Outcome prediction in patients after cardiac arrest (CA) is challenging. Electroencephalographic reactivity (EEG‐R) might be a reliable predictor. We aimed to determine the prognostic value of EEG‐R using a standardized assessment. Methods In a prospective cohort study, a strictly defined EEG‐R assessment protocol was executed twice per day in adult patients after CA. EEG‐R was classified as present or absent by 3 EEG readers, blinded to patient characteristics. Uncertain reactivity was classified as present. Primary outcome was best Cerebral Performance Category score (CPC) in 6 months after CA, dichotomized as good (CPC = 1–2) or poor (CPC = 3–5). EEG‐R was considered reliable for predicting poor outcome if specificity was ≥95%. For good outcome prediction, a specificity of ≥80% was used. Added value of EEG‐R was the increase in specificity when combined with EEG background, neurological examination, and somatosensory evoked potentials (SSEPs). Results Of 160 patients enrolled, 149 were available for analyses. Absence of EEG‐R for poor outcome prediction had a specificity of 82% and a sensitivity of 73%. For good outcome prediction, specificity was 73% and sensitivity 82%. Specificity for poor outcome prediction increased from 98% to 99% when EEG‐R was added to a multimodal model. For good outcome prediction, specificity increased from 70% to 89%. Interpretation EEG‐R testing in itself is not sufficiently reliable for outcome prediction in patients after CA. For poor outcome prediction, it has no substantial added value to EEG background, neurological examination, and SSEPs. For prediction of good outcome, EEG‐R seems to have added value. ANN NEUROL 2019
Collapse
Affiliation(s)
- Marjolein M. Admiraal
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
| | - Anne‐Fleur van Rootselaar
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Neurology/Clinical Neurophysiology, Amsterdam NeuroscienceAmsterdamthe Netherlands
| | - Jeannette Hofmeijer
- Rijnstate HospitalDepartment of NeurologyArnhemthe Netherlands
- Clinical NeurophysiologyTechMed Centre, University of TwenteEnschedethe Netherlands
| | | | | | - Hanneke M. Keijzer
- Rijnstate HospitalDepartment of NeurologyArnhemthe Netherlands
- Department of Intensive Care Medicine and NeurologyDonders Institute for Brain, Cognition, and Behavior, Radboud University Medical CenterNijmegenthe Netherlands
| | - Michel J. A. M. van Putten
- Clinical NeurophysiologyTechMed Centre, University of TwenteEnschedethe Netherlands
- Department of Clinical NeurophysiologyMedisch Spectrum TwenteEnschedethe Netherlands
| | - Marcus J. Schultz
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
- Amsterdam University Medical Centers, University of AmsterdamLaboratory for Experimental Intensive Care and AnesthesiologyAmsterdamthe Netherlands
- Mahidol UniversityMahidol Oxford Tropical Medicine Research UnitBangkokThailand
| | - Janneke Horn
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Intensive Care, Amsterdam NeuroscienceAmsterdamthe Netherlands
- Amsterdam University Medical Centers, University of AmsterdamLaboratory for Experimental Intensive Care and AnesthesiologyAmsterdamthe Netherlands
| |
Collapse
|
9
|
Johnsen B, Nøhr KB, Duez CHV, Ebbesen MQ. The Nature of EEG Reactivity to Light, Sound, and Pain Stimulation in Neurosurgical Comatose Patients Evaluated by a Quantitative Method. Clin EEG Neurosci 2017; 48:428-437. [PMID: 28844160 DOI: 10.1177/1550059417726475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
EEG reactivity (EEG-R) is regarded as an important parameter in coma prognosis but knowledge is sparse on the nature of EEG changes due to different kinds of stimulation and their prognostic significance. EEG-R was quantified in a study of 39 comatose neurosurgical patients. Six 30-second standardized visual, auditory, and painful stimulations were applied. EEG-R in the delta, theta, alpha, and beta band was normalized in z-scores as the power of a stimulation epoch relative to average power of 6 resting epochs. Outcome measure was 3 months Glasgow Outcome Scale. Increase in EEG activity was related to poor outcome, was more common (13.4% of tests), and grew continuously during the 30-second stimulation epoch. Decrease in EEG activity was related to good outcome, was rarer (2.5%), and peaked around 15 seconds. Pain was the most provocative stimulation (20.4%) followed by sound (8.7%) and eye-opening (6.7%). Discrimination between good (n = 6) and poor (n = 33) outcome was best in the theta and alpha bands for pain stimulation in the first 10-20 seconds and for sound stimulation in the first 5 to 10 seconds, eye-opening did not discriminate. Increase in activity predicted poor outcome with a high specificity 100% (CI = 52%-100%) and a modest sensitivity of 39% (CI = 23%-58%). Decrease in activity predicted good outcome with a high specificity of 100% (CI = 87%-100%) and a modest sensitivity of 33% (CI = 6%-76%). This quantitative study reveals new knowledge about the nature of EEG-R, which contribute to the development of more reliable and objective clinical procedures for outcome prediction.
Collapse
Affiliation(s)
- Birger Johnsen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kristoffer B Nøhr
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,2 Research Centre for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Q Ebbesen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|