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Misirocchi F, Quintard H, Kleinschmidt A, Schaller K, Pugin J, Seeck M, De Stefano P. ICU-Electroencephalogram Unit Improves Outcome in Status Epilepticus Patients: A Retrospective Before-After Study. Crit Care Med 2024; 52:e545-e556. [PMID: 39120451 PMCID: PMC11469622 DOI: 10.1097/ccm.0000000000006393] [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] [Indexed: 08/10/2024]
Abstract
OBJECTIVES Continuous electroencephalogram (cEEG) monitoring is recommended for status epilepticus (SE) management in ICU but is still underused due to resource limitations and inconclusive evidence regarding its impact on outcome. Furthermore, the term "continuous monitoring" often implies continuous recording with variable intermittent review. The establishment of a dedicated ICU-electroencephalogram unit may fill this gap, allowing cEEG with nearly real-time review and multidisciplinary management collaboration. This study aimed to evaluate the effect of ICU-electroencephalogram unit establishing on SE outcome and management. DESIGN Single-center retrospective before-after study. SETTING Neuro-ICU of a Swiss academic tertiary medical care center. PATIENTS Adult patients treated for nonhypoxic SE between November 1, 2015, and December 31, 2023. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Data from all SE patients were assessed, comparing those treated before and after ICU-electroencephalogram unit introduction. Primary outcomes were return to premorbid neurologic function, ICU mortality, SE duration, and ICU SE management. Secondary outcomes were SE type and etiology. Two hundred seven SE patients were included, 149 (72%) before and 58 (38%) after ICU-electroencephalogram unit establishment. ICU-electroencephalogram unit introduction was associated with increased detection of nonconvulsive SE ( p = 0.003) and SE due to acute symptomatic etiology ( p = 0.019). Regression analysis considering age, comorbidities, SE etiology, and SE semeiology revealed a higher chance of returning to premorbid neurologic function ( p = 0.002), reduced SE duration ( p = 0.024), and a shift in SE management with increased use of antiseizure medications ( p = 0.007) after ICU-electroencephalogram unit introduction. CONCLUSIONS Integrating neurology expertise in the ICU setting through the establishment of an ICU-electroencephalogram unit with nearly real-time cEEG review, shortened SE duration, and increased likelihood of returning to premorbid neurologic function, with an increased number of antiseizure medications used. Further studies are warranted to validate these findings and assess long-term prognosis.
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Affiliation(s)
- Francesco Misirocchi
- Unit of Neurology, Department of Medicine and Surgery, University of Parma, Parma, Italy
- Division of Intensive Care, Department or Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Division of Intensive Care, Department or Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Andreas Kleinschmidt
- Medical Faculty of the University of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
| | - Karl Schaller
- Medical Faculty of the University of Geneva, Geneva, Switzerland
- Department of Neurosurgery, Geneva University Medical Center & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Department or Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Medical Faculty of the University of Geneva, Geneva, Switzerland
| | - Margitta Seeck
- Medical Faculty of the University of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
| | - Pia De Stefano
- Division of Intensive Care, Department or Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
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Kayal G, Oliveira KN, Haneef Z. Survey of Continuous EEG Monitoring Practices in the United States. J Clin Neurophysiol 2024:00004691-990000000-00142. [PMID: 38916934 DOI: 10.1097/wnp.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVE Continuous EEG (cEEG) practice has markedly changed over the last decade given its utility in improving critical care outcomes. However, there are limited data describing the current cEEG infrastructure in US hospitals. METHODS A web-based cEEG practice survey was sent to neurophysiologists at 123 ACGME-accredited epilepsy or clinical neurophysiology programs. RESULTS Neurophysiologists from 100 (81.3%) institutions completed the survey. Most institutions had 3 to 10 EEG faculty (80.0%), 1 to 5 fellows (74.8%), ≥6 technologists (84.9%), and provided coverage to neurology ICUs with >10 patients (71.0%) at a time. Round-the-clock EEG technologist coverage was available at most (90.0%) institutions with technologists mostly being in-house (68.0%). Most institutions without after-hours coverage (8 of 10) attributed this to insufficient technologists. The typical monitoring duration was 24 to 48 hours (23.0 and 40.0%), most commonly for subclinical seizures (68.4%) and spell characterization (11.2%). Larger neurology ICUs had more EEG technologists ( p = 0.02), fellows ( p = 0.001), and quantitative EEG use ( p = 0.001). CONCLUSIONS This survey explores current cEEG practice patterns in the United States. Larger centers had more technologists and fellows. Overall technologist numbers are stable over time, but with a move toward more in-hospital compared with home-based coverage. Reduced availability of EEG technologists was a major factor limiting cEEG availability at some centers.
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Affiliation(s)
- Gina Kayal
- Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.; and
| | - Kristen N Oliveira
- Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.; and
| | - Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A.; and
- Neurology Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, U.S.A
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Fenter H, Rossetti AO, Beuchat I. Continuous versus Routine Electroencephalography in the Intensive Care Unit: A Review of Current Evidence. Eur Neurol 2023; 87:17-25. [PMID: 37952533 PMCID: PMC11003555 DOI: 10.1159/000535085] [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: 07/17/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Electroencephalography (EEG) has long been used to detect seizures in patients with disorders of consciousness. In recent years, there has been a drastically increased adoption of continuous EEG (cEEG) in the intensive care units (ICUs). Given the resources necessary to record and interpret cEEG, this is still not available in every center and widespread recommendations to use continuous instead of routine EEG (typically lasting 20 min) are still a matter of some debate. Considering recent literature and personal experience, this review offers a rationale and practical advice to address this question. SUMMARY Despite the development of increasingly performant imaging techniques and several validated biomarkers, EEG remains central to clinicians in the intensive care unit and has been experiencing expanding popularity for at least 2 decades. Not only does EEG allow seizure or status epilepticus detection, which in the ICU often present without clinical movements, but it is also paramount for the prognostic evaluation of comatose patients, especially after cardiac arrest, and for detecting delayed ischemia after subarachnoid hemorrhage. At the end of the last Century, improvements of technical and digital aspects regarding recording and storage of EEG tracings have progressively led to the era of cEEG and automated quantitative analysis. KEY MESSAGES As compared to repeated rEEG, cEEG in comatose patients does not seem to improve clinical prognosis to a relevant extent, despite allowing a more performant of detection ictal events and consequent therapeutic modifications. The choice between cEEG and rEEG must therefore always be patient-tailored.
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Affiliation(s)
- Helene Fenter
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Isabelle Beuchat
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
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Mohamed AT, El Rakawy MH, Abdelhamid YAE, Hazzou AM, Wahid el din MM. Stroke-related early seizures: clinical and neurophysiological study in a sample of Egyptian population. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023. [DOI: 10.1186/s41983-022-00603-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract
Background
Available data collected from patients of different types of acute cerebrovascular strokes can detect risk factors, clinical data (including semiology of seizures), EEG findings and functional outcome of these patients. Stroke, both ischemic and hemorrhagic, has been considered an essential cause of epilepsy, especially in the elderly. Complications of acute stroke during the early days after the insult determine the ultimate outcome of events. The aim of this study is to determine the clinical and neurophysiological characteristics of stroke patients with or without clinical evident fits for early detection and better management.
Results
The brain imaging of the cases group who developed seizures showed that 50% of the cases have arterial ischemic infarction, 30% venous infarction, 6.67% ischemic infarction with haemorrhagic transformation, 6.67% intracerebral haemorrhage and 6.67% have subarachnoid haemorrhage. Based on the 2017 ILAE criteria, 43.33% of the patients developed focal to bilateral tonic clonic seizures, 33.33% developed focal aware seizures, 16.67% of the patients developed generalized tonic clonic seizures and 6.67% of the patient developed status epilepticus. EEG findings of the group of patients who developed seizures showed, focal slowing in 46.67%, focal epileptiform activity in 13.33%, focal activity with secondary generalization in 10%, PLEDS in 6.67%, generalized epileptiform activity in 6.67%, generalized slowing in 6.67% and normal EEG in 10% of the patients. Non convulsive status was found in 2 patients (6.67%) of the group with altered mental status. There was no PLEDS in EEG of group of patients without clinical seizures. This study did not find age and sex differences in patients with and without seizures. In addition, it was found that there was no statistically significant difference between the three groups as regard history of diabetes mellitus, hypertension, heart diseases, atrial fibrillation, carotid stenosis and collagen diseases. There was no significant relationship between seizures and early treatment with Rtpa and thrombectomy.
Conclusions
Focal to bilateral tonic clonic and focal aware seizures were the most prevalent type of early onset seizures after stroke, followed by generalized tonic clonic seizures and status epilepticus. Most EEG findings in this study were focal slowing, focal epileptiform activities, generalized epileptiform activities and PLEDS.
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Bozarth XL, Ko PY, Bao H, Abend NS, Watson RS, Qu P, Dervan LA, Morgan LA, Wainwright M, McGuire JK, Novotny E. Use of Continuous EEG Monitoring and Short-Term Outcomes in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1749433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThis study aimed to compare short-term outcomes at pediatric intensive care unit (PICU) discharge in critically ill children with and without continuous electroencephalography (cEEG) monitoring. We retrospectively compared 234 patients who underwent cEEG with 2294 patients without cEEG. Propensity score matching was used to compare patients with seizures and status epilepticus between cEEG and historical cohorts. The EEG cohort had higher in-hospital mortality, worse Pediatric Cerebral Performance Category (PCPC) scores, and greater PCPC decline at discharge. In patients with status epilepticus, the PCPC decline was higher in the cEEG cohort. PCPC decline at PICU discharge was associated with cEEG monitoring in patients with status epilepticus.
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Affiliation(s)
- Xiuhua Liang Bozarth
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Pin-Yi Ko
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Hao Bao
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Nicholas S. Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Pingping Qu
- Biostatistics, Epidemiology, Econometrics and Programming Core, Seattle Children's Research Institute, Washington, United States
| | - Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Lindsey A. Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - Mark Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
| | - John K. McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Edward Novotny
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, United States
- Center for Integrative Brain Research, Seattle Children's Research Institute, Washington, United States
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Amerineni R, Sun H, Lee H, Hsu J, Patorno E, Westover MB, Zafar SF. Using electronic health data to explore effectiveness of ICU EEG and anti-seizure treatment. Ann Clin Transl Neurol 2021; 8:2270-2279. [PMID: 34802196 PMCID: PMC8670316 DOI: 10.1002/acn3.51478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives The purpose of this study was to examine critical care continuous electroencephalography (cEEG) utilization and downstream anti‐seizure treatment patterns, their association with outcomes, and generate hypotheses for larger comparative effectiveness studies of cEEG‐guided interventions. Methods Single‐center retrospective study of critically ill patients (n = 14,523, age ≥18 years). Exposure defined as ≥24 h of cEEG and subsequent anti‐seizure medication (ASM) escalation, with or without concomitant anesthetic. Exposure window was the first 7 days of admission. Primary outcome was in‐hospital mortality. Multivariable analysis was performed using penalized logistic regression. Results One thousand and seventy‐three patients underwent ≥24 h of cEEG within 7 days of admission. After adjusting for disease severity, ≥24 h of cEEG followed by ASM escalation in patients not on anesthetics (n = 239) was associated with lower in‐hospital mortality (OR 0.76 [0.53–1.07]), though the finding did not reach significance. ASM escalation with concomitant anesthetic use (n = 484) showed higher odds for mortality (OR 1.41 [1.03–1.94]). In the seizures/status epilepticus subgroup, post cEEG ASM escalation without anesthetics showed lower odds for mortality (OR 0.43 [0.23–0.74]). Within the same subgroup, ASM escalation with concomitant anesthetic use showed higher odds for mortality (OR 1.34 [0.92–1.91]) though not significant. Interpretation Based on our findings we propose the following hypotheses for larger comparative effectiveness studies investigating the direct causal effect of cEEG‐guided treatment on outcomes: (1) cEEG‐guided ASM escalation may improve outcomes in critically ill patients with seizures; (2) cEEG‐guided treatment with combination of ASMs and anesthetics may not improve outcomes in all critically ill patients.
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Affiliation(s)
- Rajesh Amerineni
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hang Lee
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Hsu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Rossetti AO, Schindler K, Sutter R, Rüegg S, Zubler F, Novy J, Oddo M, Warpelin-Decrausaz L, Alvarez V. Continuous vs Routine Electroencephalogram in Critically Ill Adults With Altered Consciousness and No Recent Seizure: A Multicenter Randomized Clinical Trial. JAMA Neurol 2021; 77:1225-1232. [PMID: 32716479 PMCID: PMC7385681 DOI: 10.1001/jamaneurol.2020.2264] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question In patients with acute consciousness impairment and no recent seizures, does continuous electroencephalogram (cEEG) correlate with reduced mortality compared with repeated routine EEG (rEEG)? Findings In this pragmatic, multicenter randomized clinical trial analyzing 364 adults, cEEG translated into a higher rate of seizures/status epilepticus detection and antiseizure treatment modifications but did not improve mortality compared with rEEG. Meaning Pending larger studies, rEEG may represent a valid alternative to cEEG in centers with limited resources. Importance In critically ill patients with altered consciousness, continuous electroencephalogram (cEEG) improves seizure detection, but is resource-consuming compared with routine EEG (rEEG). It is also uncertain whether cEEG has an effect on outcome. Objective To assess whether cEEG is associated with reduced mortality compared with rEEG. Design, Setting, and Participants The pragmatic multicenter Continuous EEG Randomized Trial in Adults (CERTA) was conducted between 2017 and 2018, with follow-up of 6 months. Outcomes were assessed by interviewers blinded to interventions.The study took place at 4 tertiary hospitals in Switzerland (intensive and intermediate care units). Depending on investigators’ availability, we pragmatically recruited critically ill adults having Glasgow Coma Scale scores of 11 or less or Full Outline of Responsiveness score of 12 or less, without recent seizures or status epilepticus. They had cerebral (eg, brain trauma, cardiac arrest, hemorrhage, or stroke) or noncerebral conditions (eg, toxic-metabolic or unknown etiology), and EEG was requested as part of standard care. An independent physician provided emergency informed consent. Interventions Participants were randomized 1:1 to cEEG for 30 to 48 hours vs 2 rEEGs (20 minutes each), interpreted according to standardized American Clinical Neurophysiology Society guidelines. Main Outcomes and Measures Mortality at 6 months represented the primary outcome. Secondary outcomes included interictal and ictal features detection and change in therapy. Results We analyzed 364 patients (33% women; mean [SD] age, 63 [15] years). At 6 months, mortality was 89 of 182 in those with cEEG and 88 of 182 in those with rEEG (adjusted relative risk [RR], 1.02; 95% CI, 0.83-1.26; P = .85). Exploratory comparisons within subgroups stratifying patients according to age, premorbid disability, comorbidities on admission, deeper consciousness reduction, and underlying diagnoses revealed no significant effect modification. Continuous EEG was associated with increased detection of interictal features and seizures (adjusted RR, 1.26; 95% CI, 1.08-1.15; P = .004 and 3.37; 95% CI, 1.63-7.00; P = .001, respectively) and more frequent adaptations in antiseizure therapy (RR, 1.84; 95% CI, 1.12-3.00; P = .01). Conclusions and Relevance This pragmatic trial shows that in critically ill adults with impaired consciousness and no recent seizure, cEEG leads to increased seizure detection and modification of antiseizure treatment but is not related to improved outcome compared with repeated rEEG. Pending larger studies, rEEG may represent a valid alternative to cEEG in centers with limited resources. Trial Registration ClinicalTrials.gov Identifier: NCT03129438
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Kaspar Schindler
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Frédéric Zubler
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Loane Warpelin-Decrausaz
- Clinical Trial Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Alvarez
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Department of Neurology, Hôpital du Valais, Sion, Switzerland
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Abstract
Continuous video-EEG (cEEG, lasting hours to several days) is increasingly used in ICU patients, as it is more sensitive than routine video-EEG (rEEG, lasting 20-30 min) to detect seizures or status epilepticus, and allows more frequent changes in therapeutic regimens. However, cEEG is more resource-consuming, and its relationship to outcome compared to repeated rEEG has only been formally assessed very recently in a randomized controlled trial, which did not show any significant difference in terms of long-term mortality or functional outcome. Awaiting more refined trials, it seems therefore that using repeated rEEG in ICU patients may represent a reasonable alternative in resource-limited settings. Prolonged EEG has been used recently in patients with severe COVID-19 infection, the proportion of seizures seems albeit relatively low, and similar to ICU patients with medical conditions. As in any case a timely EEG recording is recommended in the ICU, r ecent technical developments may ease its use in clinical practice.
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Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland -
| | - Jong W Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Rossetti AO, Schindler K, Alvarez V. Assessment of a Study of Continuous vs Repeat-Spot Electroencephalography in Patients With Critical Illness-Reply. JAMA Neurol 2021; 78:369-370. [PMID: 33523097 DOI: 10.1001/jamaneurol.2020.5343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kaspar Schindler
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Vincent Alvarez
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Neurology, Hôpital du Valais, Sion, Switzerland
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Limotai C, Ingsathit A, Thadanipon K, Pattanaprateep O, Pattanateepapon A, Phanthumchinda K, Suwanwela NC, Thaipisuttikul I, Boonyapisit K, Thakkinstian A. Efficacy and economic evaluation of delivery of care with tele-continuous EEG in critically ill patients: a multicentre, randomised controlled trial (Tele-cRCT) study protocol. BMJ Open 2020; 10:e033195. [PMID: 32139485 PMCID: PMC7059544 DOI: 10.1136/bmjopen-2019-033195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Some critically ill patients are confirmed by continuous electroencephalography (cEEG) monitoring that non-convulsive seizure (NCS) and/or non-convulsive status epilepticus (NCSE) are causes of their depressed level of consciousness. Shortage of epilepsy specialists, especially in developing countries, is a major limiting factor in implementing cEEG in general practice. Delivery of care with tele-continous EEG (tele-cEEG) may be a potential solution as this allows specialists from a central facility to remotely assist local neurologists from distant areas in interpreting EEG findings and suggest proper treatment. No tele-cEEG programme has been implemented to help improve quality of care. Therefore, this study is conducted to assess the efficacy and cost utility of implementing tele-cEEG in critical care. METHODS AND ANALYSIS The Tele-cRCT study is a 3-year prospective, randomised, controlled, parallel, multicentre, superiority trial comparing delivery of care through 'Tele-cEEG' intervention with 'Tele-routine EEG (Tele-rEEG)' in patients with clinical suspicion of NCS/NCSE. A group of EEG specialists and a tele-EEG system were set up to remotely interpret EEG findings in six regional government hospitals across Thailand. The primary outcomes are functional neurological outcome (modified Rankin Scale, mRS), mortality rate and incidence of seizures. The secondary outcomes are cost utility, length of stay, emergency visit/readmission, impact on changing medical decisions and health professionals' perceptions about tele-cEEG implementation. Functional outcome (mRS) will be assessed at 3 and 7 days after recruitment, and again at time of hospital discharge, and at 90 days, 6 months, 9 months and 1 year. Costs and health-related quality of life will be assessed using the Thai version of the EuroQol-five dimensions-five levels (EQ-5D-5L) at hospital discharge, and at 90 days, 6 months, 9 months and 1 year. ETHICS AND DISSEMINATION This study has been approved by the ethics committees of the Faculty of Medicine, Chulalongkorn University, and of Ramathibodi Hospital, Mahidol University, and registered on Thai Clinical Trials Registry. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER TCTR20181022002; preresults.
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Affiliation(s)
- Chusak Limotai
- Division of Neurology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Kunlawat Thadanipon
- Department of Clinical Epidemiology and Biostatistics, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Anuchate Pattanateepapon
- Department of Clinical Epidemiology and Biostatistics, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Kammant Phanthumchinda
- Division of Neurology, Department of Medicine, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Nijasri C Suwanwela
- Division of Neurology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Iyavut Thaipisuttikul
- Division of Neurology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanokwan Boonyapisit
- Division of Neurology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Mahidol University Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
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Current Status of Continuous Electroencephalographic Monitoring in Critically Ill Children. Pediatr Neurol 2019; 101:11-17. [PMID: 31493974 DOI: 10.1016/j.pediatrneurol.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/13/2019] [Accepted: 07/26/2019] [Indexed: 11/21/2022]
Abstract
The utilization of continuous electroencephalographic monitoring in critical care units has increased significantly, and several consensus statements and guidelines have been published. The use of critical care electroencephalographic monitoring has become a standard of care in many centers in the United States and other countries. The most common indication is to detect electrographic seizures and status epilepticus. Other indications include monitoring treatment efficacy in patients with electrographic seizures and status epilepticus, evaluating the degree of disturbance of function in patients with encephalopathy, monitoring brain function in patients treated with sedation and neuromuscular blocking agents, and event characterization. The urgent initiation of critical care electroencephalographic monitoring is recommended in certain clinical populations, but varies among institutions. The consensus among neurologists is to start treatment after identifying electrographic seizures or electrographic status epilepticus with or without clinical signs. However, the optimal treatment of nonconvulsive and electrographic-only seizures remains controversial. Critical care electroencephalographic monitoring has significant impact on clinical management, but there is lack of clear evidence that treatment guided by critical care electroencephalographic monitoring leads to improvement of clinical and neurodevelopmental outcome. There are substantial discrepancies among institutions on personnel and technical support used for critical care electroencephalographic monitoring. The optimal critical care electroencephalographic monitoring team should include electroencephalographers with experience in critical care electroencephalographic monitoring interpretation and appropriately trained technologists certified in electroencephalography by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists specializing in critical care electroencephalographic monitoring or long-term monitoring.
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Hill CE, Blank LJ, Thibault D, Davis KA, Dahodwala N, Litt B, Willis AW. Continuous EEG is associated with favorable hospitalization outcomes for critically ill patients. Neurology 2018; 92:e9-e18. [PMID: 30504428 DOI: 10.1212/wnl.0000000000006689] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/29/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To characterize continuous EEG (cEEG) use patterns in the critically ill and to determine the association with hospitalization outcomes for specific diagnoses. METHODS We performed a retrospective cross-sectional study with National Inpatient Sample data from 2004 to 2013. We sampled hospitalized adult patients who received intensive care and then compared patients who underwent cEEG to those who did not. We considered diagnostic subgroups of seizure/status epilepticus, subarachnoid or intracerebral hemorrhage, and altered consciousness. Outcomes were in-hospital mortality, hospitalization cost, and length of stay. RESULTS In total, 7,102,399 critically ill patients were identified, of whom 22,728 received cEEG. From 2004 to 2013, the proportion of patients who received cEEG increased from 0.06% (95% confidence interval [CI] 0.03%-0.09%) to 0.80% (95% CI 0.62%-0.98%). While the cEEG cohort appeared more ill, cEEG use was associated with reduced in-hospital mortality after adjustment for patient and hospital characteristics (odds ratio [OR] 0.83, 95% CI 0.75-0.93, p < 0.001). This finding held for the diagnoses of subarachnoid or intracerebral hemorrhage and for altered consciousness but not for the seizure/status epilepticus subgroup. Cost and length of hospitalization were increased for the cEEG cohort (OR 1.17 and OR 1.11, respectively, p < 0.001). CONCLUSIONS There was a >10-fold increase in cEEG use from 2004 to 2013. However, this procedure may still be underused; cEEG was associated with lower in-hospital mortality but used for only 0.3% of the critically ill population. While administrative claims analysis supports the utility of cEEG for critically ill patients, our findings suggest variable benefit by diagnosis, and investigation with greater clinical detail is warranted.
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Affiliation(s)
- Chloe E Hill
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia.
| | - Leah J Blank
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Dylan Thibault
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Kathryn A Davis
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Nabila Dahodwala
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Brian Litt
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
| | - Allison W Willis
- From the Department of Neurology (C.E.H., L.J.B., D.T., K.A.D., N.D., B.L., A.W.W.), Leonard Davis Institute of Health Economics (C.E.H., N.D., A.W.W.), Translational Center of Excellence for Neurology Outcomes Research, Department of Neurology (D.T., A.W.W.), and Department of Biostatistics, Epidemiology and Informatics (A.W.W.), University of Pennsylvania, Philadelphia
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Does Continuous Video-EEG in Patients With Altered Consciousness Improve Patient Outcome? Current Evidence and Randomized Controlled Trial Design. J Clin Neurophysiol 2018. [DOI: 10.1097/wnp.0000000000000467] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Khawaja AM, Pati S, Ng YT. Management of Epilepsy Due to Hypothalamic Hamartomas. Pediatr Neurol 2017; 75:29-42. [PMID: 28886982 DOI: 10.1016/j.pediatrneurol.2017.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/28/2017] [Accepted: 07/01/2017] [Indexed: 11/18/2022]
Abstract
A hypothalamic hamartoma consists of hyperplastic heterotopic tissue growing in a disorganized fashion. These lesions occur in about one per 50,000 to 100,000 people. Hypothalamic hamartomas can cause intrinsic epileptogenesis leading to gelastic seizures. Surrounding cortical structures may also develop secondary epileptogenesis. Persistent seizures caused by hypothalamic hamartomas can be debilitating and result in significant cognitive and behavioral impairment. Early recognition and treatment is important in controlling seizures and in preventing further cognitive deterioration. Some patients experience improved cognition and behavior following early treatment, suggesting that hypothalamic hamartomas represent a reversible epileptic encephalopathy. The outcome of epilepsy associated with these lesions has significantly evolved with the availability of new treatment techniques and an improved understanding of its pathogenesis. Increasing evidence supporting the role of hypothalamic hamartomas as a cause of gelastic seizures and secondary epileptogenesis has led to more frequent use of surgery as the definitive treatment. Several minimally invasive procedures have been devised, including neuroendoscopic approaches and different stereotactic radio and laser ablation techniques. Each of these techniques can lead to unique adverse events. We review the various classification schemes used to characterize hypothalamic hamartomas and the recommended surgical approaches for each subtype. We also review the literature for currently available treatment modalities and compare their efficacy in controlling seizures and their safety profiles.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama.
| | - Yu-Tze Ng
- Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, Texas
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