Acute seizures after intracerebral hemorrhage

Vespa, Paul; O’Phelan, Kristine; Shah, M. Mohsin; Mirabelli, J.; Starkman, Sidney; Kidwell, Chelsea S.; Saver, Jeffrey; Nuwer, Marc R.; Frazee, John G.; McArthur, D.A.; Martin, Neil A.

doi:10.1212/01.wnl.0000063316.47591.b4

Cited by 530 publications

(348 citation statements)

References 35 publications

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“…The detection of delirium symptoms in patients with acute ICH mean 6 days after ICH onset (not at the time of presentation, as one might have expected) was independently predictive of mean 3.5-day longer ICU LOS, nearly nine times the odds of poor functional outcomes at 1 month, and nearly a SD worse lower QOL in applied cognition-executive function and fatigue. This independent effect on functional outcomes (good vs. poor outcome) at 1 month, a reliable time for outcome assessment (22), is important given that it was present after correction for NIHSS and age, strong predictors of outcome in this population (28). These data underscore that delirium symptoms, which may be overlooked because of ICH, had implications for outcomes independent of the severity of the underlying neurologic injury.…”

Section: Discussionmentioning

confidence: 80%

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Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Naidech

Beaumont²,

Rosenberg³

et al. 2013

Am J Respir Crit Care Med

100

105

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Rationale: The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear. Objectives: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage. Methods: We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months. Measurements and Main Results: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P ¼ 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P ¼ 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up. Conclusions: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL. Keywords: delirium; outcomes; quality of lifeThe symptoms of delirium, a potential consequence of multiple clinical disease states and physiologic aberrations, include a shift in baseline mental status, inattention, and disorganized thinking or altered level of consciousness. Although nonspecific, this syndrome is an independent predictor of higher mortality (1), longer length of stay (LOS), higher cost of care, and worse long-term cognitive outcomes in medical, surgical, burn, and trauma intensive care unit (ICU) patients (2). There are few such data, however, in ICU patients with focal neurologic injury without systemic illness.Risk factors for delirium symptoms are typically global (infection [3] and intravenous sedation, particularly benzodiazepines [BZDs]) (4, 5) as opposed to focal lesions (e.g., hematoma). Most mechanically ventilated patients are delirious during hospitalization (1), potentially because of the sedation regimen (e.g., BZD infusion), but sedation is typically minimized in neurologically injured patients to permit repeated neurologic assessment that may lead to an acute intervention (6).Screening tests for delirium have been recently validated in neurologically ill patients (7-9), including ischemic stroke (7, 10) and intracerebra...

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Section: Discussionmentioning

confidence: 80%

“…When QOL was reported by a proxy, we repeated the model with QOL scores corrected for proxy report with data from Neuro-QOL validation studies. We adjusted models for age and NIHSS, a previously accepted model for outcome prediction (20,28). Calculations were made with standard statistical software (SPSS v. 21; IBM, Armonk, NY).…”

Section: Discussionmentioning

confidence: 99%

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Naidech

Beaumont²,

Rosenberg³

et al. 2013

Am J Respir Crit Care Med

100

105

View full text Add to dashboard Cite

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“…Seizures were more common with lobar hemorrhages (23%) than in deep hemorrhages (11%). Hemorrhage expansion and perihematomal edema resulting in midline shift have been associated with seizure, although the direction of causation is not established [14,17]. To best allocate resources, guidelines have been focusing on recommending prolonged EEG for the detection of seizures in patients who have depressed mental status or a neurological examination out of proportion to the degree of documented brain injury [16].…”

Section: Patient Selectionmentioning

confidence: 99%

The Utility of EEG, SSEP, and Other Neurophysiologic Tools to Guide Neurocritical Care

Rosenthal

2012

Neurotherapeutics

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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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“…Indeed, seizures are frequent after a variety of hemorrhagic injuries to the brain (3,4). The incidence of seizures increases as a function of the severity of injury, and other selected features of the injury such as the presence of hemorrhagic contusions.…”

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confidence: 99%

Nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis

Vespa

Miller²,

McArthur³

et al. 2007

Critical Care Medicine

367

148

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Objective-To determine whether nonconvulsive electrographic post-traumatic seizures result in increases in intracranial pressure and microdialysis lactate/pyruvate ratio. Design-Prospective monitoring with retrospective data analysis.Setting-Single center academic neurologic intensive care unit.Patients-Twenty moderate to severe traumatic brain injury patients (Glasgow Coma Score 3-13). HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptMeasurements and Main Results-Continuous electroencephalography and cerebral microdialysis were performed for 7 days after injury. Ten patients had seizures and were compared with a matched cohort of traumatic brain injury patients without seizures. The seizures were repetitive and constituted status epilepticus in seven of ten patients. Using a within-subject design, post-traumatic seizures resulted in episodic increases in intracranial pressure (22.4 ± 7 vs. 12.8 ± 4.3 mm Hg; p < .001) and an episodic increase in lactate/pyruvate ratio (49.4 ± 16 vs. 23.8 ± 7.6; p < .001) in the seizure group. Using a between-subjects comparison, the seizure group demonstrated a higher mean intracranial pressure (17.6 ± 6.5 vs. 12.2 ± 4.2 mm Hg; p < .001), a higher mean lactate/pyruvate ratio (38.6 ± 18 vs. 27 ± 9; p < .001) compared with nonseizure patients. The intracranial pressure and lactate/pyruvate ratio remained elevated beyond postinjury hr 100 in the seizure group but not the nonseizure group (p < .02).Conclusion-Post-traumatic seizures result in episodic as well as long-lasting increases in intracranial pressure and microdialysis lactate/pyruvate ratio. Intracranial pressure (ICP) remains one of the principal treatment targets for traumatic brain injury (TBI) (1). Elevation of ICP is due to brain edema, mass effect from hemorrhagic lesions, and possibly from disrupted pressure autoregulation. The treatments for ICP have been focused on these pathophysiologic mechanisms. While the treatment principals for elevated ICP have been codified into guidelines and practiced by many intensivists, ICP often remains refractory to treatment. Indeed, treatment failure resulting in herniation and death occurs frequently. The mechanisms for persistently elevated ICP have not been well elucidated, but candidate mechanisms include sustained hyperemia, excitotoxicity, and osmotic rebound. In contrast, little attention has been paid to the adverse effects of epileptic activity upon the extent or duration of elevated ICP after TBI.In recent years, post-traumatic seizures have been documented to occur frequently after human TBI (2). Indeed, seizures are frequent after a variety of hemorrhagic injuries to the brain (3, 4). The incidence of seizures increases as a function of the severity of injury, and other selected features of the injury such as the presence of hemorrhagic contusions. Posttraumatic seizures previously have been associated with increased glycolysis in both animal and human metabolic imaging studies (5, 6) and have been associated with alterat...

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Acute seizures after intracerebral hemorrhage

Abstract: Seizures occur commonly after ICH and may be nonconvulsive. Seizures are independently associated with increased midline shift after intraparenchymal hemorrhage.

Cited by 530 publications

References 35 publications

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

Intracerebral Hemorrhage and Delirium Symptoms. Length of Stay, Function, and Quality of Life in a 114-Patient Cohort

The Utility of EEG, SSEP, and Other Neurophysiologic Tools to Guide Neurocritical Care

Nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis

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