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Greenblatt AS, Beniczky S, Nascimento FA. Pitfalls in scalp EEG: Current obstacles and future directions. Epilepsy Behav 2023; 149:109500. [PMID: 37931388 DOI: 10.1016/j.yebeh.2023.109500] [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] [Received: 09/02/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
Although electroencephalography (EEG) serves a critical role in the evaluation and management of seizure disorders, it is commonly misinterpreted, resulting in avoidable medical, social, and financial burdens to patients and health care systems. Overinterpretation of sharply contoured transient waveforms as being representative of interictal epileptiform abnormalities lies at the core of this problem. However, the magnitude of these errors is amplified by the high prevalence of paroxysmal events exhibited in clinical practice that compel investigation with EEG. Neurology training programs, which vary considerably both in the degree of exposure to EEG and the composition of EEG didactics, have not effectively addressed this widespread issue. Implementation of competency-based curricula in lieu of traditional educational approaches may enhance proficiency in EEG interpretation amongst general neurologists in the absence of formal subspecialty training. Efforts in this regard have led to the development of a systematic, high-fidelity approach to the interpretation of epileptiform discharges that is readily employable across medical centers. Additionally, machine learning techniques hold promise for accelerating accurate and reliable EEG interpretation, particularly in settings where subspecialty interpretive EEG services are not readily available. This review highlights common diagnostic errors in EEG interpretation, limitations in current educational paradigms, and initiatives aimed at resolving these challenges.
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Affiliation(s)
- Adam S Greenblatt
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fábio A Nascimento
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Parikh H, Hoffman K, Sun H, Zafar SF, Ge W, Jing J, Liu L, Sun J, Struck A, Volfovsky A, Rudin C, Westover MB. Effects of epileptiform activity on discharge outcome in critically ill patients in the USA: a retrospective cross-sectional study. Lancet Digit Health 2023; 5:e495-e502. [PMID: 37295971 PMCID: PMC10528143 DOI: 10.1016/s2589-7500(23)00088-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Epileptiform activity is associated with worse patient outcomes, including increased risk of disability and death. However, the effect of epileptiform activity on neurological outcome is confounded by the feedback between treatment with antiseizure medications and epileptiform activity burden. We aimed to quantify the heterogeneous effects of epileptiform activity with an interpretability-centred approach. METHODS We did a retrospective, cross-sectional study of patients in the intensive care unit who were admitted to Massachusetts General Hospital (Boston, MA, USA). Participants were aged 18 years or older and had electrographic epileptiform activity identified by a clinical neurophysiologist or epileptologist. The outcome was the dichotomised modified Rankin Scale (mRS) at discharge and the exposure was epileptiform activity burden defined as mean or maximum proportion of time spent with epileptiform activity in 6 h windows in the first 24 h of electroencephalography. We estimated the change in discharge mRS if everyone in the dataset had experienced a specific epileptiform activity burden and were untreated. We combined pharmacological modelling with an interpretable matching method to account for confounding and epileptiform activity-antiseizure medication feedback. The quality of the matched groups was validated by the neurologists. FINDINGS Between Dec 1, 2011, and Oct 14, 2017, 1514 patients were admitted to Massachusetts General Hospital intensive care unit, 995 (66%) of whom were included in the analysis. Compared with patients with a maximum epileptiform activity of 0 to less than 25%, patients with a maximum epileptiform activity burden of 75% or more when untreated had a mean 22·27% (SD 0·92) increased chance of a poor outcome (severe disability or death). Moderate but long-lasting epileptiform activity (mean epileptiform activity burden 2% to <10%) increased the risk of a poor outcome by mean 13·52% (SD 1·93). The effect sizes were heterogeneous depending on preadmission profile-eg, patients with hypoxic-ischaemic encephalopathy or acquired brain injury were more adversely affected compared with patients without these conditions. INTERPRETATION Our results suggest that interventions should put a higher priority on patients with an average epileptiform activity burden 10% or greater, and treatment should be more conservative when maximum epileptiform activity burden is low. Treatment should also be tailored to individual preadmission profiles because the potential for epileptiform activity to cause harm depends on age, medical history, and reason for admission. FUNDING National Institutes of Health and National Science Foundation.
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Affiliation(s)
- Harsh Parikh
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Kentaro Hoffman
- Deptartment of Statistics and Operation Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Wendong Ge
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lin Liu
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Institute of Natural Sciences, MOELSC, School of Mathematical Sciences and SJTU-Yale Joint Center for Biostatistics and Data Science, Shanghai Jiao Tong University, Shanghai, China
| | - Jimeng Sun
- The Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana-Champaign, IL, USA
| | - Aaron Struck
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Cynthia Rudin
- Department of Computer Science, Duke University, Durham, NC, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Capecchi F, di Giacopo A, Keller E, Mothershill I, Imbach LL. Stimulus Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDs) and its Association with Non-convulsive Status Epilepticus in Critically Ill Patients. Clin EEG Neurosci 2022; 54:247-254. [PMID: 35473446 PMCID: PMC10084515 DOI: 10.1177/15500594221095434] [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: 11/15/2022]
Abstract
Stimulus induced repetitive periodic or ictal discharges (SIRPIDs) are a commonly observed EEG pattern in critically ill patients. However, the epileptic significance of SIRPIDs remain unclear. We identified and reviewed 55 cases with SIRPIDs according to the ACNS criteria. SIRPIDs occurred after standardized painful stimuli during a standard 20-minute EEG. These cases were investigated regarding their relation to non-convulsive status epilepticus (NCSE) according to Salzburg Consensus Criteria and in-hospital mortality. In 37/55 patients (67.3%), SIRPIDs were associated with NCSE. In most patients (26/37 cases, 70.3%) with concurrent status epilepticus, SIRPIDs occurred after status epilepticus (on average 4.8 days later), but in 3/37 patients (8.1%) they were observed before a later status epilepticus. In four cases (4/37 cases, 10.8%), SIRPIDs appeared both before and after an episode of NCSE and in other four cases the two patterns coexisted in the same EEG. In 50% of the patients, status epilepticus was refractory, super-refractory or the patient died before its resolution. The overall mortality in the cohort was high at 58.2%. These findings corroborate the hypothesis that SIRPIDs might represent a state with increased epileptogenic potential, commonly co-occurring with NCSE. Furthermore, SIRPIDs are associated with therapy-refractory course of status epilepticus and high mortality.
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Affiliation(s)
- Francesco Capecchi
- Department of Neurology, 27243University Hospital and University of Zurich, Zurich, Switzerland
| | - Andrea di Giacopo
- Department of Neurology, Ente Ospedaliero Cantonale, 31033Lugano, Switzerland
| | - Emanuela Keller
- Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ian Mothershill
- 31033Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich, Switzerland
| | - Lukas L Imbach
- 31033Swiss Epilepsy Clinic, Klinik Lengg AG, Zurich, Switzerland
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Saito S, Iijima M, Seki M, Yoshizawa H, Kitagawa K. [MRI arterial spin labeling is useful for diagnosing recovery from nonconvulsive status epilepticus with sustained periodic discharges]. Rinsho Shinkeigaku 2021; 62:49-52. [PMID: 34924466 DOI: 10.5692/clinicalneurol.cn-001636] [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] [Indexed: 11/05/2022]
Abstract
A 75-year-old man with a history of temporal lobe epilepsy (treated with levetiracetam) was transferred to our hospital because of loss of consciousness. At admission, he was drowsy and exhibited myoclonus on the left side of face. We established a diagnosis of status epilepticus and started treatment with levetiracetam, fosphenytoin, and midazolam. FLAIR and DWI showed hyperintensity in the right cerebral cortex. Electroencephalography (EEG) showed lateralized periodic discharges (LPDs) at the right hemisphere, indicative of non-convulsive status epilepticus (NCSE). He regained consciousness after treatment with anti-epileptic drugs but showed persistent LPDs in EEG. MRI arterial spin labeling (ASL) showed normal perfusion in the right hemisphere; therefore, he was deemed to have recovered from status epilepticus and transferred to the rehabilitation hospital. MRI ASL is useful for diagnosing recovery from NCSE irrespective of sustained periodic discharges on EEG.
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Affiliation(s)
- Satoshi Saito
- Department of Neurology, Tokyo Women's Medical University School of Medicine
| | - Mutsumi Iijima
- Department of Neurology, Tokyo Women's Medical University School of Medicine
| | - Misa Seki
- Department of Neurology, Tokyo Women's Medical University School of Medicine
| | - Hiroshi Yoshizawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine
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