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Handan Günsay R, Çıkrıkçı Işık G, Yıldırım M, Gökçek Ö, Korucu O, Çevik Y. Evaluation of postictal optic nerve sheath diameter at epileptic patients. Epilepsy Behav 2023; 144:109264. [PMID: 37247582 DOI: 10.1016/j.yebeh.2023.109264] [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: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION During a seizure, metabolic rate and, consequently, cerebral blood flow increase to provide the required maintenance energy. It is thought that this causes an increase in intracranial pressure, but there is no comprehensive research on this subject. In this study, we aimed to measure and follow optic nerve sheath diameter (ONSD) in patients who applied to the emergency department (ED) after generalized tonic-clonic (GTC) seizures and to gain information about intracranial pressure changes in epilepsy patients in the postictal period. MATERIALS AND METHODS This was a prospective observational study. Patients already diagnosed with epilepsy who applied to the ED within one hour after GTC seizures were included. The ONSD of the patients was measured by the same radiologist three times in both eyes using ultrasonography at the time of admission and the fourth hour of follow-up. The seizure characteristics and measurements of the patients were recorded, and the changes in ONSD over time and correlations between seizure characteristics and ONSD were examined. RESULTS Sixty-six patients were included in the study. Thirty-four (51.5%) of the patients had seizures with auras. For both eyes, the first-hour ONSD values of the patients [right: 5.90 (5.73-6.16) mm, left: 5.86 (5.73-6.13) mm] were significantly higher than the fourth-hour ONSD values [right: 5.26 (5.19-5.40) mm, left: 5.28 (5.16-5.36) mm)] (p < 0.001 for both eyes). Additionally, the first- and fourth-hour ONSD values of patients with seizures with auras were significantly higher than those with seizures without auras (p < 0.001 for each condition). There was no correlation between other variables related to seizure type and ONSD. CONCLUSION This study showed that after GTC seizures in epilepsy patients, ONSD increases in the first hour postictal and decreases over time. Another important result is that the increase in ONSD values in seizures with auras is significantly higher than in seizures without auras.
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Affiliation(s)
- Rabia Handan Günsay
- University of Health Sciences Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
| | - Gülşah Çıkrıkçı Işık
- University of Health Sciences Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
| | - Meral Yıldırım
- Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
| | - Özcan Gökçek
- University of Health Sciences Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Radiology, Ankara, Turkey.
| | - Osman Korucu
- University of Health Sciences Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Neurology, Ankara, Turkey.
| | - Yunsur Çevik
- University of Health Sciences Ankara Atatürk Sanatoryum Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
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Davis JA, Grau JW. Protecting the injured central nervous system: Do anesthesia or hypothermia ameliorate secondary injury? Exp Neurol 2023; 363:114349. [PMID: 36775099 DOI: 10.1016/j.expneurol.2023.114349] [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: 11/10/2022] [Revised: 01/13/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Traumatic injury to the central nervous system (CNS) and stroke initiate a cascade of processes that expand the area of tissue loss. The current review considers recent studies demonstrating that the induction of an anesthetic state or cooling the affected tissue (hypothermia) soon after injury can have a therapeutic effect. We first provide an overview of the neurobiological processes that fuel tissue loss after traumatic brain injury (TBI), spinal cord injury (SCI) and stroke. We then examine the rehabilitative effectiveness of therapeutic anesthesia across a variety of drug categories through a systematic review of papers in the PubMed database. We also review the therapeutic benefits hypothermia, another treatment that quells neural activity. We conclude by considering factors related to the safety, efficacy and timing of treatment, as well as the mechanisms of action. Clinical implications are also discussed.
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Affiliation(s)
- Jacob A Davis
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA.
| | - James W Grau
- Cellular and Behavioral Neuroscience, Department of Psychology, Texas A&M University, College Station, TX 77843, USA
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Anania P, Battaglini D, Miller JP, Balestrino A, Prior A, D'Andrea A, Badaloni F, Pelosi P, Robba C, Zona G, Fiaschi P. Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary? Neurosurg Rev 2021; 44:2415-2423. [PMID: 33215367 PMCID: PMC7676754 DOI: 10.1007/s10143-020-01438-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/29/2020] [Accepted: 11/11/2020] [Indexed: 11/24/2022]
Abstract
Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.
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Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - John P Miller
- Louisiana State University, Health Sciences University, New Orleans, LA, USA
| | - Alberto Balestrino
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro D'Andrea
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Filippo Badaloni
- Division of Neurosurgery, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
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Ikawa A, Fujimoto A, Arai Y, Otsuki Y, Nozaki T, Baba S, Sato K, Enoki H. Case Report: Late-Onset Temporal Lobe Epilepsy Following Subarachnoid Hemorrhage: An Interplay Between Pre-existing Cortical Development Abnormality and Tissue Damage. Front Neurol 2021; 12:599130. [PMID: 33633663 PMCID: PMC7901922 DOI: 10.3389/fneur.2021.599130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/19/2021] [Indexed: 12/26/2022] Open
Abstract
Epileptogenicity following brain insult depends on various factors including severity of the resulting lesion and extent of brain damage. We report a 54-year-old female patient who developed medically refractory epilepsy resulting from the interplay of pre-existing and post-insult pathologies. She presented with subarachnoid hemorrhage (SAH) due to a ruptured aneurysm and underwent clipping surgery. Seizures started 3 months post-operatively. MRI revealed cerebral ischemia and hemosiderin deposits in the left temporal lobes, and left hippocampal atrophy was suspected. As anti-seizure medications and vagus nerve stimulation failed to control her seizures, she underwent left temporal lobe resection and placement of a ventriculoperitoneal shunt for the post-operative complication of hydrocephalus. She remains seizure-free to date. Neuropathology revealed a previously undiagnosed focal cortical dysplasia (FCD) type 1a. Brain insult likely had a second hit effect in the late onset of epilepsy in this patient with pre-existing mild MCD, in whom secondary epilepsy can be attributed to the interplay of multiple underlying pathologies.
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Affiliation(s)
- Anna Ikawa
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan.,Department of Neurosurgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan.,Department of Neurosurgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshifumi Arai
- Department of Pathology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshiro Otsuki
- Department of Pathology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Toshiki Nozaki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Shimpei Baba
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Keishiro Sato
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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Gafner M, Lerman-Sagie T, Constantini S, Roth J. Refractory epilepsy associated with ventriculoperitoneal shunt over-drainage: case report. Childs Nerv Syst 2019; 35:2411-2416. [PMID: 31492981 DOI: 10.1007/s00381-019-04367-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/02/2019] [Indexed: 11/30/2022]
Abstract
Epilepsy and intracranial pressure (ICP) can be interrelated. While shunt malfunction is recognized as a cause of seizures, shunt over-drainage is seldom reported as such. We report a child who had undergone ventriculoperitoneal shunt insertion at the age of 6 months following an excision of a left ventricle choroid plexus papilloma, who developed refractory epilepsy since the age of 3 years. An MRI showed small ventricles. The child presented with acute hydrocephalus due to proximal shunt malfunction at the age of 11 years and was treated with an endoscopic third ventriculostomy. Following the procedure, the seizures abated. Our case suggests that intractable epilepsy may be related to intracranial hypotension. Potential treatments for shunt over-drainage may be indicated even in the absence of classic over-drainage symptoms, in the presence of refractory epilepsy.
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Affiliation(s)
- Michal Gafner
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tally Lerman-Sagie
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel
| | - Shlomi Constantini
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel
| | - Jonathan Roth
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel. .,Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizman Street, 64239, Tel Aviv, Israel.
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Uchida D, Fujimoto A, Yamazoe T, Yamamoto T, Enoki H. Seizure frequency can be reduced by changing intracranial pressure: A case report in drug-resistant epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:14-17. [PMID: 30062085 PMCID: PMC6063982 DOI: 10.1016/j.ebcr.2017.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022]
Abstract
A relationship between seizures and intracranial pressure (ICP) has been proposed, but not clearly identified. Whether changes in ICP can evoke seizures remains controversial. We report the case of a 23-year-old man who had undergone shunt surgery in childhood and later presented with focal impaired awareness seizures and behavior arrest. Seizures were uncontrolled despite 3 years of pharmacotherapy, but suddenly stopped after shunt removal. Our case supports the hypothesis that drug-resistant epilepsy can be influenced by changes in ICP. In particular, this case indicates that elevations in ICP may help reduce some seizures. A rare case indicating the relationship between drug-resistant epilepsy and ICP Drug-resistant epilepsy stopped just after a symptomatic increase in ICP. Seizures were controlled well by adjusting shunt valve pressure. This case suggests that elevations in ICP may help reduce seizures.
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Affiliation(s)
- Daiki Uchida
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Tomohiro Yamazoe
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Takamichi Yamamoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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7
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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9
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Abstract
To determine the optimal use and indications of electroencephalography (EEG) in critical care management of acute brain injury (ABI). An electronic literature search was conducted for articles in English describing electrophysiological monitoring in ABI from January 1990 to August 2013. A total of 165 studies were included. EEG is a useful monitor for seizure and ischemia detection. There is a well-described role for EEG in convulsive status epilepticus and cardiac arrest (CA). Data suggest EEG should be considered in all patients with ABI and unexplained and persistent altered consciousness and in comatose intensive care unit (ICU) patients without an acute primary brain condition who have an unexplained impairment of mental status. There remain uncertainties about certain technical details, e.g., the minimum duration of EEG studies, the montage, and electrodes. Data obtained from both EEG and EP studies may help estimate prognosis in ABI patients, particularly following CA and traumatic brain injury. Data supporting these recommendations is sparse, and high quality studies are needed. EEG is used to monitor and detect seizures and ischemia in ICU patients and indications for EEG are clear for certain disease states, however, uncertainty remains on other applications.
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Hansen G, Joffe AR, Bowman SM, Richer L. Nonconvulsive seizures and status epilepticus in pediatric head trauma: A national survey. SAGE Open Med 2015; 3:2050312115573817. [PMID: 26770768 PMCID: PMC4679225 DOI: 10.1177/2050312115573817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 01/22/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES It remains uncertain whether nonconvulsive seizures and nonconvulsive status epilepticus in pediatric traumatic brain injury are deleterious to the brain and/or impact the recovery from injury. Consequently, optimal electroencephalographic surveillance and management is unknown. We aimed to determine specialists' opinion regarding the detection and treatment of nonconvulsive seizures or nonconvulsive status epilepticus in pediatric traumatic brain injury, regardless of their practice. METHODS In 2012, 183 surveys were sent to all 93 neurologists, 27 neurosurgeons, and 63 intensivists in the14 tertiary pediatric hospitals across Canada. The survey included an initial scenario of pediatric TBI that evolved into three further scenarios. Each scenario had required responses and an embedded branching logic algorithm ascertaining clinical management. The survey instrument assimilated data about the importance of nonconvulsive status epilepticus and nonconvulsive seizures detection and treatment, and whether they are a cause of brain injury that adversely affects neurologic outcomes. RESULTS Of the 79 specialists who replied (43% response rate), 68%-78% elected to order an electroencephalographic across all four scenarios, and one-third (31%-36%; scenario dependent) would request an urgent electroencephalographic (within the hour) in the comatose pediatric traumatic brain injury patient. In the absence of pharmacologic paralysis or intracranial pressure spikes, half-hour electroencephalographic (41%-55%) was preferred over ⩾24-h continuous electroencephalographic monitoring (29%-40%). Finally, nonconvulsive status epilepticus (81%-87%) and nonconvulsive seizures (61%-73%) were considered to be a cause of poor neurologic outcomes warranting aggressive pharmacologic management. CONCLUSION The Canadian specialists' opinion is that nonconvulsive seizures and nonconvulsive status epilepticus are biomarkers of brain injury and contribute to worsened outcomes. This suggests the urgency of future outcome-oriented research in the identification and management of nonconvulsive seizures or nonconvulsive status epilepticus.
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Affiliation(s)
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Stephen M Bowman
- Johns Hopkins University, Baltimore, MD, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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11
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Severe traumatic brain injury management and clinical outcome using the Lund concept. Neuroscience 2014; 283:245-55. [DOI: 10.1016/j.neuroscience.2014.06.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 02/04/2023]
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Affiliation(s)
- Nino Stocchetti
- From the Department of Pathophysiology and Transplantation, Milan University, and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda-Ospedale Maggiore Policlinico - both in Milan (N.S.); and the Department of Neurosurgery, Antwerp University Hospital-University of Antwerp, Edegem, Belgium (A.I.R.M.)
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Pandin P, Renard M, Bianchini A, Desjardin P, Obbergh LV. Monitoring Brain and Spinal Cord Metabolism and Function. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojanes.2014.46020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lindgren C, Nordh E, Naredi S, Olivecrona M. Frequency of non-convulsive seizures and non-convulsive status epilepticus in subarachnoid hemorrhage patients in need of controlled ventilation and sedation. Neurocrit Care 2013; 17:367-73. [PMID: 22932991 DOI: 10.1007/s12028-012-9771-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Non-convulsive seizures (NCSZ) can be more prevalent than previously recognized among comatose neuro-intensive care patients. The aim of this study was to evaluate the frequency of NCSZ and non-convulsive status epilepticus (NCSE) in sedated and ventilated subarachnoid hemorrhage (SAH) patients. METHODS Retrospective study at a university hospital neuro-intensive care unit, from January 2008 until June 2010. Patients were treated according to a local protocol, and were initially sedated with midazolam or propofol or combinations of these sedative agents. Thiopental was added for treatment of intracranial hypertension. No wake-up tests were performed. Using NicoletOne(®) equipment (VIASYS Healthcare Inc., USA), continuous EEG recordings based on four electrodes and a reference electrode was inspected at full length both in a two electrode bipolar and a four-channel referential montage. RESULTS Approximately 5,500 h of continuous EEG were registered in 28 SAH patients (33 % of the patients eligible for inclusion). The median Glasgow Coma scale was 8 (range 3-14) and the median Hunt and Hess score was 4 (range 1-4). During EEG registration, no clinical seizures were observed. In none of the patients inter ictal epileptiform activity was seen. EEG seizures were recorded only in 2/28 (7 %) patients. One of the patients experienced 4 min of an NCSZ and one had a 5 h episode of an NCSE. CONCLUSION Continuous EEG monitoring is important in detecting NCSZ in sedated patients. Continuous sedation, without wake-up tests, was associated with a low frequency of subclinical seizures in SAH patients in need of controlled ventilation.
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Affiliation(s)
- Cecilia Lindgren
- Division of Anaesthesiology and Intensive Care, Department of Surgical and Perioperative Sciences, University of Umeå, 90187, Umeå, Sweden.
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Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39:1337-51. [PMID: 23653183 DOI: 10.1007/s00134-013-2938-4] [Citation(s) in RCA: 247] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/14/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Recommendations for EEG monitoring in the ICU are lacking. The Neurointensive Care Section of the ESICM assembled a multidisciplinary group to establish consensus recommendations on the use of EEG in the ICU. METHODS A systematic review was performed and 42 studies were included. Data were extracted using the PICO approach, including: (a) population, i.e. ICU patients with at least one of the following: traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, stroke, coma after cardiac arrest, septic and metabolic encephalopathy, encephalitis, and status epilepticus; (b) intervention, i.e. EEG monitoring of at least 30 min duration; (c) control, i.e. intermittent vs. continuous EEG, as no studies compared patients with a specific clinical condition, with and without EEG monitoring; (d) outcome endpoints, i.e. seizure detection, ischemia detection, and prognostication. After selection, evidence was classified and recommendations developed using the GRADE system. RECOMMENDATIONS The panel recommends EEG in generalized convulsive status epilepticus and to rule out nonconvulsive seizures in brain-injured patients and in comatose ICU patients without primary brain injury who have unexplained and persistent altered consciousness. We suggest EEG to detect ischemia in comatose patients with subarachnoid hemorrhage and to improve prognostication of coma after cardiac arrest. We recommend continuous over intermittent EEG for refractory status epilepticus and suggest it for patients with status epilepticus and suspected ongoing seizures and for comatose patients with unexplained and persistent altered consciousness. CONCLUSIONS EEG monitoring is an important diagnostic tool for specific indications. Further data are necessary to understand its potential for ischemia assessment and coma prognostication.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Division of Critical Care Neurology, Columbia University Medical Center, New York, NY, USA
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Abstract
PURPOSE OF REVIEW To review recent clinical data and summarize actual recommendations for the management of electrographic seizures and status epilepticus in neuro-ICU patients. RECENT FINDINGS Electrographic, 'nonconvulsive', seizures are frequent in neuro-ICU patients including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage and hypoxic-ischemic encephalopathy. Continuous electroencephalography monitoring is thus of great potential utility. The impact of electrographic seizures on outcome however is not entirely established and it is also unclear what type of electroencephalography paroxysms require treatment and when and how exactly to treat them. Evidence from randomized studies is lacking and will not be available in the near future. Given robust animal and human evidence showing the potential negative impact of seizures on secondary cerebral damage and outcome, treatment of seizures appears reasonable, particularly if related to status epilepticus. On the contrary, over-aggressive antiepileptic therapy entails risks. The management of seizures should therefore be guided individually, based on the underlying cause, the severity of illness and patient comorbidities. SUMMARY We provide a pragmatic approach for the management of electrographic seizures in neuro-ICU patients. International consensus guidelines on continuous electroencephalography monitoring and seizure therapy are needed and would represent the rationale for a future multicenter randomized trial.
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Abstract
BACKGROUND Non-convulsive seizures have been reported to be common in neurocritical care patients. Many jurisdictions do not have sufficient resources to enable routine continuous electroencephalography (cEEG) and instead use primarily intermittent EEG, for which the diagnostic yield remains uncertain. Determining risk factors for epileptiform activity and seizures could help identify patients who might particularly benefit from EEG monitoring. METHODS We performed a cohort study involving neurocritical care patients with admission Glascow Coma Scale (GCS) scores ≤ 12, who underwent ≥ 1 EEG. EEGs were reviewed for presence of interictal discharges, periodic epileptiform discharges (PEDs), and seizures. Multivariate analysis was used to identify predictors of these findings and to describe their prognostic implications. RESULTS 393 patients met inclusion criteria. 34 underwent cEEG, usually because epileptiform activity was first detected on a routine EEG. The prevalence of PEDs or electrographic seizures was 13%, and was highest with anoxic encephalopathy and central nervous system infections. Other independent predictors for epileptiform activity included a history of convulsive seizure(s), increasing age, deeper coma, and female gender. Although patients with epileptiform activity had higher mortality, this association disappeared after adjustment for confounders. CONCLUSION Approximately 7-8 neurocritical care patients must undergo intermittent EEG monitoring in order to diagnose one with PEDs or seizures. The predictors we identified could potentially help guide use of resources. Repeated intermittent studies, or cEEG, should be considered in patients with multiple risk factors, or when interictal discharges are identified on an initial EEG. It remains unclear whether aggressive prevention and treatment of electrographic seizures improves neurologic outcomes.
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Abstract
Two different main concepts for the treatment of a severe traumatic brain injury have been established during the last 15 years, namely the more conventional concept recommended in well-established guidelines (eg, U.S. Guideline, European Guideline, Addelbrook's Guideline from Cambridge), on the one hand, and the Lund concept from the University Hospital of Lund, Sweden, on the other. Owing to the lack of well-controlled randomized outcome studies comparing these 2 main therapeutic approaches, we cannot conclude that one is better than the other. This paper is the PRO part in a PRO-CON debate in this journal on the Lund concept. Although the Lund concept is based on a physiology-oriented approach dealing with the hemodynamic principles of brain volume and brain perfusion regulation, traditional treatments are primarily based on a meta-analytic approach from clinical studies. High cerebral perfusion pressure has been an essential goal in the conventional treatments (the cerebral perfusion pressure-guided approach), even though it has been modified in a recent up date of U.S. guidelines. The Lund concept has instead concentrated on management of brain edema and intracranial pressure, along with improvement of cerebral perfusion and oxygenation (the intracranial pressure and perfusion-guided approach). Although conventional guidelines are restricted to clinical data from meta-analytic surveys, the physiological approach of Lund therapy finds support in both experimental and clinical studies. It offers a wider base and can also provide recommendations regarding fluid therapy, lung protection, optimal hemoglobin concentration, temperature control, the use of decompressive craniotomy, and ventricular drainage. This paper puts forward arguments in support of Lund therapy.
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Rosenthal ES. The utility of EEG, SSEP, and other neurophysiologic tools to guide neurocritical care. Neurotherapeutics 2012; 9:24-36. [PMID: 22234455 PMCID: PMC3271154 DOI: 10.1007/s13311-011-0101-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Neuromonitoring is an emerging field that aims to characterize real-time neurophysiology to tailor therapy for acute injuries of the central nervous system. While cardiac telemetry has been used for decades among patients requiring critical care of all kinds, neurophysiology and neurotelemetry has only recently emerged as a routine screening tool in comatose patients. The increasing utilization of electroencephalography in comatose patients is primarily due to the recognition of the common occurrence of nonconvulsive seizures among comatose patients, the development of quantitative measures to detect regional ischemia, and the appreciation of electroencephalography phenotypes that indicate prognosis after cardiac arrest. Other neuromonitoring tools, such as somatosensory evoked potentials have a complementary role, surveying the integrity of the neuroaxis as an indicator of prognosis or illness progression in both acute brain and spinal injuries.
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Affiliation(s)
- Eric S Rosenthal
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
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Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LOD. Prostacyclin treatment and clinical outcome in severe traumatic brain injury patients managed with an ICP-targeted therapy: A prospective study. Brain Inj 2011; 26:67-75. [DOI: 10.3109/02699052.2011.635351] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stewart CP, Otsubo H, Ochi A, Sharma R, Hutchison JS, Hahn CD. Seizure identification in the ICU using quantitative EEG displays. Neurology 2010; 75:1501-8. [PMID: 20861452 DOI: 10.1212/wnl.0b013e3181f9619e] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of 2 quantitative EEG display tools, color density spectral array (CDSA) and amplitude-integrated EEG (aEEG), for seizure identification in the intensive care unit (ICU). METHODS A set of 27 continuous EEG recordings performed in pediatric ICU patients was transformed into 8-channel CDSA and aEEG displays. Three neurophysiologists underwent 2 hours of training to identify seizures using these techniques. They were then individually presented with a series of CDSA and aEEG displays, blinded to the raw EEG, and asked to mark any events suspected to be seizures. Their performance was compared to seizures identified on the underlying conventional EEG. RESULTS The 27 EEG recordings contained 553 discrete seizures over 487 hours. The median sensitivity for seizure identification across all recordings was 83.3% using CDSA and 81.5% using aEEG. However, among individual recordings, the sensitivity ranged from 0% to 100%. Factors reducing the sensitivity included low-amplitude, short, and focal seizures. False-positive rates were generally very low, with misidentified seizures occurring once every 17-20 hours. CONCLUSIONS Both CDSA and aEEG demonstrate acceptable sensitivity and false-positive rates for seizure identification among critically ill children. Accuracy of these tools would likely improve during clinical use, when findings can be correlated in real-time with the underlying raw EEG. In the hands of neurophysiologists, CDSA and aEEG displays represent useful screening tools for seizures during continuous EEG monitoring in the ICU. The suitability of these tools for bedside use by ICU nurses and physicians requires further study.
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Affiliation(s)
- C P Stewart
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
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