Continuous vs Routine Electroencephalogram in Critically Ill Adults With Altered Consciousness and No Recent Seizure

Abstract

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.

Standardized visual EEG features predict outcome in patients with acute consciousness impairment of various etiologies

“…We performed a post hoc analysis of data prospectively acquired during the multicentric study CERTA (Continuous EEG Randomized Trial in Adults; NCT03129438). Details of the study have been published elsewhere [ 32 , 33 ]. In short, patients > 18 with disorder of consciousness of any etiology (defined as GCS ≤ 11 or FOUR ≤ 12) hospitalized on the Intensive or Intermediate Care Units of four Swiss hospitals (Lausanne University Hospital (CHUV), Sion Hospital, Bern University Hospital (Inselspital), Basel University Hospital) for whom an EEG was requested for medical reasons were included.…”

Informed consent in critically ill adults participating to a randomized trial

“…It involved four large Swiss hospitals (CHUV Lausanne; Hôpital du Valais; Inselspital Bern; Universitätsspital Basel). Between April 2017 and November 2018, adults with acute consciousness impairment in an intensive/intermediate care unit needing an EEG for clinical purposes were pragmatically recruited and randomized 1:1 to a cEEG (30–48 hr) or 2 rEEG (20 min each; Rossetti et al., 2020; intervention not blinded). The original protocol may be found in the Supporting Information.…”

Continuous EEG in ICU: Not a Luxury After All

“…With Continuous EEG Randomized Trial in Adults (CERTA), Rossetti et al 11 aimed to assess the impact of performing rEEG as compared to cEEG in patients with AMS secondary to acute brain injury or systemic conditions. The primary outcome was mortality at 6 months and secondary outcomes were reported seizures and medication changes at 4 and 6 weeks following randomization.…”