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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.
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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.
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Benghanem S, Sharshar T, Gavaret M, Dumas F, Diehl JL, Brechot N, Picard F, Candia-Rivera D, Le MP, Pène F, Cariou A, Hermann B. Heart rate variability for neuro-prognostication after CA: Insight from the Parisian registry. Resuscitation 2024:110294. [PMID: 38925291 DOI: 10.1016/j.resuscitation.2024.110294] [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: 04/08/2024] [Revised: 05/31/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Hypoxic ischemic brain injury (HIBI) induced by cardiac arrest (CA) seems to predominate in cortical areas and to a lesser extent in the brainstem. These regions play key roles in modulating the activity of the autonomic nervous system (ANS), that can be assessed through analyses of heart rate variability (HRV). The objective was to evaluate the prognostic value of various HRV parameters to predict neurological outcome after CA. METHODS Retrospective monocentric study assessing the prognostic value of HRV markers and their association with HIBI severity. Patients admitted for CA who underwent EEG for persistent coma after CA were included. HRV markers were computed from 5 min signal of the ECG lead of the EEG recording. HRV indices were calculated in the time-, frequency-, and non-linear domains. Frequency-domain analyses differentiated very low frequency (VLF 0.003-0.04 Hz), low frequency (LF 0.04-0.15 Hz), high frequency (HF 0.15-0.4 Hz), and LF/HF ratio. HRV indices were compared to other prognostic markers: pupillary light reflex, EEG, N20 on somatosensory evoked potentials (SSEP) and biomarkers (neuron specific enolase-NSE). Neurological outcome at 3 months was defined as unfavorable in case of best CPC 3-4-5. RESULTS Between 2007 and 2021, 199 patients were included. Patients were predominantly male (64%), with a median age of 60 [48.9-71.7] years. 76% were out-of-hospital CA, and 30% had an initial shockable rhythm. Neurological outcome was unfavorable in 73%. Compared to poor outcome, patients with a good outcome had higher VLF (0.21 vs 0.09 ms2/Hz, p < 0.01), LF (0.07 vs 0.04 ms2/Hz, p = 0.003), and higher LF/HF ratio (2.01 vs 1.01, p = 0.008). Several non-linear domain indices were also higher in the good outcome group, such as SD2 (15.1 vs 10.2, p = 0.016) and DFA α1 (1.03 vs 0.78, p = 0.002). These indices also differed depending on the severity of EEG pattern and abolition of pupillary light reflex. These time-frequency and non-linear domains HRV parameters were predictive of poor neurological outcome, with high specificity despite a low sensitivity. CONCLUSION In comatose patients after CA, some HRV markers appear to be associated with unfavorable outcome, EEG severity and PLR abolition, although the sensitivity of these HRV markers remains limited.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France.
| | - Tarek Sharshar
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Neuro-ICU, GHU Paris Sainte Anne, Paris, France
| | - Martine Gavaret
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Neurophysiology and Epileptology Department, GHU Paris Sainte Anne, Paris, France
| | - Florence Dumas
- University Paris Cité, Medical School, Paris F-75006, France; Emergency Department, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Jean-Luc Diehl
- University Paris Cité, Medical School, Paris F-75006, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
| | - Nicolas Brechot
- University Paris Cité, Medical School, Paris F-75006, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
| | - Fabien Picard
- University Paris Cité, Medical School, Paris F-75006, France; Cardiology Department, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Diego Candia-Rivera
- Institut du Cerveau et de la Moelle épinière - ICM, INSERM U1127, CNRS UMR 7225, F-75013 Paris, France
| | - Minh-Pierre Le
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France
| | - Frederic Pène
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France
| | - Alain Cariou
- Medical Intensive Care Unit, APHP.Paris Centre, Cochin Hospital, Paris, France; University Paris Cité, Medical School, Paris F-75006, France
| | - Bertrand Hermann
- University Paris Cité, Medical School, Paris F-75006, France; INSERM 1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM UMR 1266, Paris, France; Medical ICU, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris F-75015, France
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Benghanem S, Kubis N, Gayat E, Loiodice A, Pruvost-Robieux E, Sharshar T, Foucrier A, Figueiredo S, Bouilleret V, De Montmollin E, Bagate F, Lefaucheur JP, Guidet B, Appartis E, Cariou A, Varnet O, Jost PH, Megarbane B, Degos V, Le Guennec L, Naccache L, Legriel S, Woimant F, Gregoire C, Cortier D, Crassard I, Timsit JF, Mazighi M, Sonneville R. Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study. Crit Care 2024; 28:173. [PMID: 38783313 PMCID: PMC11119574 DOI: 10.1186/s13054-024-04957-5] [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: 04/07/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Prognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and prevalence of early electroencephalogram (EEG) abnormalities in adult stroke patients receiving mechanical ventilation. METHODS This study is a pre-planned ancillary investigation within the prospective multicenter SPICE cohort study (2017-2019), conducted in 33 intensive care units (ICUs) in the Paris area, France. We included adult stroke patients requiring invasive mechanical ventilation, who underwent at least one intermittent EEG examination during their ICU stay. The primary endpoint was the functional neurological outcome at one year, determined using the modified Rankin scale (mRS), and dichotomized as unfavorable (mRS 4-6, indicating severe disability or death) or favorable (mRS 0-3). Multivariable regression analyses were employed to identify EEG abnormalities associated with functional outcomes. RESULTS Of the 364 patients enrolled in the SPICE study, 153 patients (49 ischemic strokes, 52 intracranial hemorrhages, and 52 subarachnoid hemorrhages) underwent at least one EEG at a median time of 4 (interquartile range 2-7) days post-stroke. Rates of diffuse slowing (70% vs. 63%, p = 0.37), focal slowing (38% vs. 32%, p = 0.15), periodic discharges (2.3% vs. 3.7%, p = 0.9), and electrographic seizures (4.5% vs. 3.7%, p = 0.4) were comparable between patients with unfavorable and favorable outcomes. Following adjustment for potential confounders, an unreactive EEG background to auditory and pain stimulations (OR 6.02, 95% CI 2.27-15.99) was independently associated with unfavorable outcomes. An unreactive EEG predicted unfavorable outcome with a specificity of 48% (95% CI 40-56), sensitivity of 79% (95% CI 72-85), and positive predictive value (PPV) of 74% (95% CI 67-81). Conversely, a benign EEG (defined as continuous and reactive background activity without seizure, periodic discharges, triphasic waves, or burst suppression) predicted favorable outcome with a specificity of 89% (95% CI 84-94), and a sensitivity of 37% (95% CI 30-45). CONCLUSION The absence of EEG reactivity independently predicts unfavorable outcomes at one year in severe stroke patients requiring mechanical ventilation in the ICU, although its prognostic value remains limited. Conversely, a benign EEG pattern was associated with a favorable outcome.
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Affiliation(s)
- Sarah Benghanem
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
| | - Nathalie Kubis
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Clinical Physiology Department, UMRS_1144, Université Paris Cite, Paris, France
| | - Etienne Gayat
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université Paris Cite, Paris, France
| | | | - Estelle Pruvost-Robieux
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
- Neurophysiology and Epileptology Department, GHU Psychiatry & Neurosciences, Sainte Anne, Paris, France
| | - Tarek Sharshar
- University Paris Cité, Medical School, Paris, France
- Department of Neuroanesthesiology and Intensive Care, Sainte Anne Hospital, Paris, France
| | - Arnaud Foucrier
- APHP, Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France
| | - Samy Figueiredo
- APHP, Department of Anesthesiology and Critical Care, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | - Viviane Bouilleret
- Neurophysiology and Epileptology Department, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | | | - François Bagate
- APHP, Department of Intensive Care Medicine, Henri Mondor University Hospital and Université de Paris Est Créteil, Créteil, France
| | | | - Bertrand Guidet
- APHP, Department of Intensive Care Medicine, Saint Antoine University Hospital, Paris, France
| | - Emmanuelle Appartis
- Neurophysiology Department, Saint Antoine University Hospital, Paris, France
| | - Alain Cariou
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
| | - Olivier Varnet
- APHP, Department of Physiology, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Paul Henri Jost
- APHP, Department of Anesthesiology and Intensive Care, Henri Mondor Hospital, Creteil, France
| | | | - Vincent Degos
- APHP, Department of Anesthesiology and Neurointensive Care, Pitié Salpétrière Hospital, Paris, France
| | - Loic Le Guennec
- APHP, Medical ICU, Pitié Salpétrière Hospital, Paris, France
| | - Lionel Naccache
- APHP, Department of Physiology, Pitié Salpétrière Hospital, Paris, France
| | | | | | - Charles Gregoire
- Department of Intensive Care, Rothschild Hospital Foundation, Paris, France
| | - David Cortier
- Department of Intensive Care, Foch Hospital, Paris, France
| | | | - Jean-François Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France
| | - Mikael Mazighi
- APHP Nord, Department of Neurology, Lariboisière University Hospital, Department of Interventional Neuroradiology, Fondation Rothschild Hospital, FHU Neurovasc, Paris, France
- Université Paris Cité, INSERM UMR 1144, Paris, France
| | - Romain Sonneville
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France.
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France.
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Hermann B, Candia‐Rivera D, Sharshar T, Gavaret M, Diehl J, Cariou A, Benghanem S. Aberrant brain-heart coupling is associated with the severity of post cardiac arrest brain injury. Ann Clin Transl Neurol 2024; 11:866-882. [PMID: 38243640 PMCID: PMC11021613 DOI: 10.1002/acn3.52000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/24/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To investigate autonomic nervous system activity measured by brain-heart interactions in comatose patients after cardiac arrest in relation to the severity and prognosis of hypoxic-ischemic brain injury. METHODS Strength and complexity of bidirectional interactions between EEG frequency bands (delta, theta, and alpha) and ECG heart rate variability frequency bands (low frequency, LF and high frequency, HF) were computed using a synthetic data generation model. Primary outcome was the severity of brain injury, assessed by (i) standardized qualitative EEG classification, (ii) somatosensory evoked potentials (N20), and (iii) neuron-specific enolase levels. Secondary outcome was the 3-month neurological status, assessed by the Cerebral Performance Category score [good (1-2) vs. poor outcome (3-4-5)]. RESULTS Between January 2007 and July 2021, 181 patients were admitted to ICU for a resuscitated cardiac arrest. Poor neurological outcome was observed in 134 patients (74%). Qualitative EEG patterns suggesting high severity were associated with decreased LF/HF. Severity of EEG changes were proportional to higher absolute values of brain-to-heart coupling strength (p < 0.02 for all brain-to-heart frequencies) and lower values of alpha-to-HF complexity (p = 0.049). Brain-to-heart coupling strength was significantly higher in patients with bilateral absent N20 and correlated with neuron-specific enolase levels at Day 3. This aberrant brain-to-heart coupling (increased strength and decreased complexity) was also associated with 3-month poor neurological outcome. INTERPRETATION Our results suggest that autonomic dysfunctions may well represent hypoxic-ischemic brain injury post cardiac arrest pathophysiology. These results open avenues for integrative monitoring of autonomic functioning in critical care patients.
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Affiliation(s)
- Bertrand Hermann
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
| | - Diego Candia‐Rivera
- Sorbonne Université, Paris Brain Institute (ICM), INRIA, CNRS UMR 722, INSERM U1127, AP‐HP Hôpital Pitié‐SalpêtrièreParisFrance
| | - Tarek Sharshar
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- GHU Paris Psychiatrie Neurosciences, Service hospitalo‐universitaire de Neuro‐anesthésie réanimationParisFrance
| | - Martine Gavaret
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Neurophysiology and Epileptology DepartmentGHU Paris Psychiatrie et NeurosciencesParisFrance
| | - Jean‐Luc Diehl
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- Université Paris Cité, INSERM, Innovative Therapies in HaemostasisParisFrance
- Biosurgical Research Lab (Carpentier Foundation)ParisFrance
| | - Alain Cariou
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
- Paris‐Cardiovascular‐Research‐CenterINSERM U970ParisFrance
| | - Sarah Benghanem
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
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Alnes SL, Bächlin LZM, Schindler K, Tzovara A. Neural complexity and the spectral slope characterise auditory processing in wakefulness and sleep. Eur J Neurosci 2024; 59:822-841. [PMID: 38100263 DOI: 10.1111/ejn.16203] [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: 03/10/2023] [Revised: 10/11/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023]
Abstract
Auditory processing and the complexity of neural activity can both indicate residual consciousness levels and differentiate states of arousal. However, how measures of neural signal complexity manifest in neural activity following environmental stimulation and, more generally, how the electrophysiological characteristics of auditory responses change in states of reduced consciousness remain under-explored. Here, we tested the hypothesis that measures of neural complexity and the spectral slope would discriminate stages of sleep and wakefulness not only in baseline electroencephalography (EEG) activity but also in EEG signals following auditory stimulation. High-density EEG was recorded in 21 participants to determine the spatial relationship between these measures and between EEG recorded pre- and post-auditory stimulation. Results showed that the complexity and the spectral slope in the 2-20 Hz range discriminated between sleep stages and had a high correlation in sleep. In wakefulness, complexity was strongly correlated to the 20-40 Hz spectral slope. Auditory stimulation resulted in reduced complexity in sleep compared to the pre-stimulation EEG activity and modulated the spectral slope in wakefulness. These findings confirm our hypothesis that electrophysiological markers of arousal are sensitive to sleep/wake states in EEG activity during baseline and following auditory stimulation. Our results have direct applications to studies using auditory stimulation to probe neural functions in states of reduced consciousness.
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Affiliation(s)
- Sigurd L Alnes
- Institute of Computer Science, University of Bern, Bern, Switzerland
- Zentrum für Experimentelle Neurologie, Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Lea Z M Bächlin
- Institute of Computer Science, University of Bern, Bern, Switzerland
| | - Kaspar Schindler
- Sleep-Wake-Epilepsy Center, NeuroTec, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athina Tzovara
- Institute of Computer Science, University of Bern, Bern, Switzerland
- Zentrum für Experimentelle Neurologie, Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
- Sleep-Wake-Epilepsy Center, NeuroTec, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Portell Penadés E, Alvarez V. A Comprehensive Review and Practical Guide of the Applications of Evoked Potentials in Neuroprognostication After Cardiac Arrest. Cureus 2024; 16:e57014. [PMID: 38681279 PMCID: PMC11046378 DOI: 10.7759/cureus.57014] [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] [Accepted: 03/24/2024] [Indexed: 05/01/2024] Open
Abstract
Cardiorespiratory arrest is a very common cause of morbidity and mortality nowadays, and many therapeutic strategies, such as induced coma or targeted temperature management, are used to reduce patient sequelae. However, these procedures can alter a patient's neurological status, making it difficult to obtain useful clinical information for the reliable estimation of neurological prognosis. Therefore, complementary investigations are conducted in the early stages after a cardiac arrest to clarify functional prognosis in comatose cardiac arrest survivors in the first few hours or days. Current practice relies on a multimodal approach, which shows its greatest potential in predicting poor functional prognosis, whereas the data and tools to identify patients with good functional prognosis remain relatively limited in comparison. Therefore, there is considerable interest in investigating alternative biological parameters and advanced imaging technique studies. Among these, somatosensory evoked potentials (SSEPs) remain one of the simplest and most reliable tools. In this article, we discuss the technical principles, advantages, limitations, and prognostic implications of SSEPs in detail. We will also review other types of evoked potentials that can provide useful information but are less commonly used in clinical practice (e.g., visual evoked potentials; short-, medium-, and long-latency auditory evoked potentials; and event-related evoked potentials, such as mismatch negativity or P300).
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Tao T, Lu S, Hu N, Xu D, Xu C, Li F, Wang Q, Peng Y. Prognosis of comatose patients with reduced EEG montage by combining quantitative EEG features in various domains. Front Neurosci 2023; 17:1302318. [PMID: 38144206 PMCID: PMC10748426 DOI: 10.3389/fnins.2023.1302318] [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: 09/26/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Objective As the frontoparietal network underlies recovery from coma, a limited frontoparietal montage was used, and the prognostic values of EEG features for comatose patients were assessed. Methods Collected with a limited frontoparietal EEG montage, continuous EEG recordings of 81 comatose patients in ICU were used retrospectively. By the 60-day Glasgow outcome scale (GOS), the patients were dichotomized into favorable and unfavorable outcome groups. Temporal-, frequency-, and spatial-domain features were automatically extracted for comparison. Partial correlation analysis was applied to eliminate redundant factors, and multiple correspondence analysis was used to explore discrimination between groups. Prognostic characteristics were calculated to assess the performance of EEG feature-based predictors established by logistic regression. Analyses were performed on all-patients group, strokes subgroup, and traumatic brain injury (TBI) subgroup. Results By analysis of all patients, raised burst suppression ratio (BSR), suppressed root mean square (RMS), raised power ratio of β to α rhythm (β/α), and suppressed phase-lag index between F3 and P4 (PLI [F3, P4]) were associated with unfavorable outcome, and yielded AUC of 0.790, 0.811, 0.722, and 0.844, respectively. For the strokes subgroup, the significant variables were BSR, RMS, θ/total, θ/δ, and PLI (F3, P4), while for the TBI subgroup, only PLI (F3, P4) was significant. BSR combined with PLI (F3, P4) gave the best predictor by cross-validation analysis in the all-patients group (AUC = 0.889, 95% CI: 0.819-0.960). Conclusion Features extracted from limited frontoparietal montage EEG served as valuable coma prognostic tools, where PLI (F3, P4) was always significant. Combining PLI (F3, P4) with features in other domains may achieve better performance. Significance A limited-montage EEG coupled with an automated algorithm is valuable for coma prognosis.
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Affiliation(s)
- Tao Tao
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Shiqi Lu
- Emergency Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Nan Hu
- School of Electronics and Information Engineering, Soochow University, Suzhou, Jiangsu, China
| | - Dongyang Xu
- Center for Intelligent Acoustics and Signal Processing, Huzhou Institute of Zhejiang University, Huzhou, China
| | - Chenyang Xu
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Fajun Li
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Qin Wang
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
| | - Yuan Peng
- Intensive Care Unit, The First People’s Hospital of Kunshan, Kunshan Affiliated Hospital of Jiangsu University, Kunshan, Jiangsu, China
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Ding X, Shen Z. Electroencephalography Prediction of Neurological Outcomes After Hypoxic-Ischemic Brain Injury: A Systematic Review and Meta-Analysis. Clin EEG Neurosci 2023:15500594231211105. [PMID: 37941351 DOI: 10.1177/15500594231211105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Background. Predicting neurological outcomes after hypoxic-ischemic brain injury (HIBI) is difficult. Objective. Electroencephalography (EEG) can identify acute and subacute brain abnormalities after hypoxic brain injury and predict HIBI recovery. We examined EEG's ability to predict neurologic outcomes following HIBI. Method. A PRISMA-compliant search was conducted in the Medline, Embase, Cochrane, and Central databases until January 2023. EEG-predicted neurological outcomes in HIBI patients were selected from relevant perspective and retrospective cohort studies. RevMan did meta-analysis, while QDAS2 assessed research quality. Results. Eleven studies with 3761 HIBI patients met the inclusion and exclusion criteria. We aggregated study-level estimates of sensitivity and specificity for EEG patterns determined a priori using random effect bivariate and univariate meta-analysis when appropriate. Positive indicators and anatomical area heterogeneity impacted prognosis accuracy. Funnel plots analyzed publication bias. Significant heterogeneity of greater than 80% was among the included studies with P < 0.001. The area under the curve was 0.94, the threshold effect was P < 0.001, and the sensitivity and specificity, with 95% confidence intervals, were 0.91 (0.84-0.99) and 0.86 (0.75-0.97). EEG detects status epilepticus and burst suppression with good sensitivity, specificity, and little probability of false-negative impairment result attribution. Study quality varied by domain, but patient flow and timing were well conducted in all. Conclusion. EEG can predict the outcome of HIBI with good prognostic accuracy, but more standardized cross-study protocols and descriptions of EEG patterns are needed to better evaluate its prognostic use for patients with HIBI.
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Affiliation(s)
- Xina Ding
- Department of Brain Function, Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong City, Jiangsu Province, 226001, China
| | - Zhixiao Shen
- Department of Brain Function, Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong City, Jiangsu Province, 226001, China
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Sonneville R, Benghanem S, Jeantin L, de Montmollin E, Doman M, Gaudemer A, Thy M, Timsit JF. The spectrum of sepsis-associated encephalopathy: a clinical perspective. Crit Care 2023; 27:386. [PMID: 37798769 PMCID: PMC10552444 DOI: 10.1186/s13054-023-04655-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
Sepsis-associated encephalopathy is a severe neurologic syndrome characterized by a diffuse dysfunction of the brain caused by sepsis. This review provides a concise overview of diagnostic tools and management strategies for SAE at the acute phase and in the long term. Early recognition and diagnosis of SAE are crucial for effective management. Because neurologic evaluation can be confounded by several factors in the intensive care unit setting, a multimodal approach is warranted for diagnosis and management. Diagnostic tools commonly employed include clinical evaluation, metabolic tests, electroencephalography, and neuroimaging in selected cases. The usefulness of blood biomarkers of brain injury for diagnosis remains limited. Clinical evaluation involves assessing the patient's mental status, motor responses, brainstem reflexes, and presence of abnormal movements. Electroencephalography can rule out non-convulsive seizures and help detect several patterns of various severity such as generalized slowing, epileptiform discharges, and triphasic waves. In patients with acute encephalopathy, the diagnostic value of non-contrast computed tomography is limited. In septic patients with persistent encephalopathy, seizures, and/or focal signs, magnetic resonance imaging detects brain injury in more than 50% of cases, mainly cerebrovascular complications, and white matter changes. Timely identification and treatment of the underlying infection are paramount, along with effective control of systemic factors that may contribute to secondary brain injury. Upon admission to the ICU, maintaining appropriate levels of oxygenation, blood pressure, and metabolic balance is crucial. Throughout the ICU stay, it is important to be mindful of the potential neurotoxic effects associated with specific medications like midazolam and cefepime, and to closely monitor patients for non-convulsive seizures. The potential efficacy of targeted neurocritical care during the acute phase in optimizing patient outcomes deserves to be further investigated. Sepsis-associated encephalopathy may lead to permanent neurologic sequelae. Seizures occurring in the acute phase increase the susceptibility to long-term epilepsy. Extended ICU stays and the presence of sepsis-associated encephalopathy are linked to functional disability and neuropsychological sequelae, underscoring the necessity for long-term surveillance in the comprehensive care of septic patients.
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Affiliation(s)
- Romain Sonneville
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France.
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
| | - Sarah Benghanem
- Department of Intensive Care Medicine, Cochin University Hospital, APHP, 75014, Paris, France
| | - Lina Jeantin
- Department of Neurology, Rothschild Foundation, Paris, France
| | - Etienne de Montmollin
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Marc Doman
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Augustin Gaudemer
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department Radiology, Bichat-Claude Bernard University Hospital, APHP, 75018, Paris, France
| | - Michael Thy
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Jean-François Timsit
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
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Shen H, Zaitseva D, Yang Z, Forsythe L, Joergensen S, Zone AI, Shehu J, Maghraoui S, Ghorbani A, Davila A, Issadore D, Abella BS. Brain-derived extracellular vesicles as serologic markers of brain injury following cardiac arrest: A pilot feasibility study. Resuscitation 2023; 191:109937. [PMID: 37591443 PMCID: PMC10528050 DOI: 10.1016/j.resuscitation.2023.109937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
AIM Assessment of neurologic injury within the immediate hours following out-of-hospital cardiac arrest (OHCA) resuscitation remains a major clinical challenge. Extracellular vesicles (EVs), small bodies derived from cytosolic contents during injury, may provide the opportunity for "liquid biopsy" within hours following resuscitation, as they contain proteins and RNA linked to cell type of origin. We evaluated whether micro-RNA (miRNA) from serologic EVs were associated with post-arrest neurologic outcome. METHODS We obtained serial blood samples in an OHCA cohort. Using novel microfluidic techniques to isolate EVs based on EV surface marker GluR2 (present on excitatory neuronal dendrites enriched in hippocampal tissue), we employed reverse transcription quantitative polymerase chain reaction (RT-qPCR) methods to measure a panel of miRNAs and tested association with dichotomized modified Rankin Score (mRS) at discharge. RESULTS EVs were assessed in 27 post-arrest patients between 7/3/2019 and 7/21/2022; 9 patients experienced good outcomes. Several miRNA species including miR-124 were statistically associated with mRS at discharge when measured within 6 hours of resuscitation (AUC = 0.84 for miR-124, p < 0.05). In a Kendall ranked correlation analysis, miRNA associations with outcome were not strongly correlated with standard serologic marker measurements, or amongst themselves, suggesting that miRNA provide distinct information from common protein biomarkers. CONCLUSIONS This study explores the associations between miRNAs from neuron-derived EVs (NDEs) and circulating protein biomarkers within 6 hours with neurologic outcome, suggesting a panel of very early biomarker may be useful during clinical care. Future work will be required to test larger cohorts with a broader panel of miRNA species.
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Affiliation(s)
- Hanfei Shen
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Daria Zaitseva
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zijian Yang
- Department of Radiology, Stanford University, Palo Alto, CA, USA
| | - Liam Forsythe
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Joergensen
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alea I Zone
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joana Shehu
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Maghraoui
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anahita Ghorbani
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Antonio Davila
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David Issadore
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Penn Acute Research Collaboration, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Lévi-Strauss J, Hmeydia G, Benzakoun J, Bouchereau E, Hermann B, Legouy C, Oppenheim C, Sharshar T, Gavaret M, Pruvost-Robieux E. Discrepancies in the late auditory potentials of post-anoxic patients: watch out for focal brain lesions, a pilot retrospective study. Resuscitation 2023; 187:109801. [PMID: 37085038 DOI: 10.1016/j.resuscitation.2023.109801] [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: 02/02/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
AIMS Late auditory evoked potentials, and notably mismatch negativity (MMN) and P3 responses, can be used as part of the multimodal prognostic evaluation in post-anoxic disorders of consciousness (DOC). MMN response preferentially stems from the temporal cortex and the arcuate fasciculus. Situations with discrepant evaluations, for example MMN absent but P3 present, are frequent and difficult to interpret. We hypothesize that discrepant MMN-/P3+ results could reflect a higher prevalence of lesions in MMN generating regions. This study presents correlations between neurophysiological and neuroradiological results. METHODS This retrospective study was conducted on 38 post-anoxic DOC patients. Brain lesions were analyzed on 3T MRI both anatomically and through computation of the local arcuate fasciculus fractional anisotropy values on Diffusion Tensor Imaging sequences. Neurophysiological data and outcome were also analyzed. RESULTS Our cohort included 8 MMN-/P3+, 7 MMN+/P3+, 21 MMN-/P3- and 2 MMN-/P3+ patients, assessed at a median delay of 20.5 days since cardiac arrest. Our results show that MMN-/P3+ patients tended to have fewer temporal and basal ganglia lesions than MMN-/P3- patients, and more than MMN+/P3+ patients (p-values for trend: p=0.02 for temporal and p=0.02 for basal ganglia lesions). There was a statistical difference across groups for mean fractional anisotropy values in the arcuate fasciculus (p=0.008). The percentage of patients regaining consciousness at three months in MMN-/P3+ patients was higher than in MMN-/P3- patients and lower than in MMN+/P3+ patients. CONCLUSION This study suggests that discrepancies in late auditory evoked potentials may be linked to focal post-anoxic brain lesions, visible on brain MRI.
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Affiliation(s)
- Julie Lévi-Strauss
- University Paris Cité, Paris, France Neurophysiology department, GHU Psychiatry & Neurosciences,Sainte Anne, F-75014 Paris INSERM U 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris.
| | - Ghazi Hmeydia
- University Paris Cité, Paris, France, Neuroradiology department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Joseph Benzakoun
- University Paris Cité, Paris, France, Neuroradiology department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Eléonore Bouchereau
- University Paris Cité, Paris, France Neuro-intensive care department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Bertrand Hermann
- University Paris Cité, Paris, France Neuro-intensive care department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris; University Paris Cité, Paris, France Medical intensive care unit, HEGP Hospital, Assistance Publique - Hôpitaux de Paris-Centre (APHP-Centre), Paris, France; Institut du Cerveau et de la Moelle épinière - ICM, INSERM U1127, CNRS UMR 7225, F-75013, Paris, France
| | - Camille Legouy
- University Paris Cité, Paris, France Neuro-intensive care department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Catherine Oppenheim
- University Paris Cité, Paris, France, Neuroradiology department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Tarek Sharshar
- University Paris Cité, Paris, France Neuro-intensive care department, GHU Psychiatry & Neurosciences, Sainte Anne, F-75014 Paris INSERM UMR 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Martine Gavaret
- University Paris Cité, Paris, France Neurophysiology department, GHU Psychiatry & Neurosciences,Sainte Anne, F-75014 Paris INSERM U 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
| | - Estelle Pruvost-Robieux
- University Paris Cité, Paris, France Neurophysiology department, GHU Psychiatry & Neurosciences,Sainte Anne, F-75014 Paris INSERM U 1266, FHU NeuroVasc, Institut de Psychiatrie et Neurosciences de Paris-IPNP, F-75014 Paris
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