EEG Monitoring Technique Influences the Management of Hypoxic-Ischemic Seizures in Neonates Undergoing Therapeutic Hypothermia

Abstract

Electroencephalogram (EEG) monitoring techniques for neonatal hypoxia-ischemia (HI) are evolving over time, and the specific type of EEG utilized could influence seizure diagnosis and management. We examined whether the type of EEG performed affected seizure treatment decisions (e.g., the choice and number of antiseizure drugs [ASDs]) in therapeutic hypothermia-treated neonates with HI from 2007 to 2015 in the Johns Hopkins Hospital Neonatal Intensive Care Unit. During this period, 3 different EEG monitoring protocols were utilized: Period 1 (2007-2009), single, brief conventional EEG (1 h duration) at a variable time during therapeutic hypothermia treatment, i.e., ordered when a seizure was suspected; Period 2 (2009-2013), single, brief conventional EEG followed by amplitude-integrated EEG for the duration of therapeutic hypothermia treatment and another brief conventional EEG after rewarming; and Period 3 (2014-2015), continuous video-EEG (cEEG) for the duration of therapeutic hypothermia treatment (72 h) plus for an additional 12 h during and after rewarming. One hundred and sixty-two newborns were included in this retrospective cohort study. As a function of the type and duration of EEG monitoring, we assessed the risk (likelihood) of receiving no ASD, at least 1 ASD, or ≥2 ASDs. We found that the risk of a neonate being prescribed an ASD was 46% less during Period 3 (cEEG) than during Period 1 (brief conventional EEG only) (95% CI 6-69%, p = 0.03). After adjusting for initial EEG and MRI results, compared with Period 1, there was a 38% lower risk of receiving an ASD during Period 2 (95% CI: 9-58%, p = 0.02) and a 67% lower risk during Period 3 (95% CI: 23-86%, p = 0.01). The risk ratio of receiving ≥2 ASDs was not significantly different across the 3 periods. In conclusion, in addition to the higher sensitivity and specificity of continuous video-EEG monitoring, fewer infants are prescribed an ASD when undergoing continuous forms of EEG monitoring (aEEG or cEEG) than those receiving conventional EEG. We recommend that use of continuous video-EEG be considered whenever possible, both to treat seizures more specifically and to avoid overtreatment.

Predictive value of early EEG for seizures in neonates with hypoxic–ischemic encephalopathy undergoing therapeutic hypothermia

“…This recommendation should be balanced with the risk that, without EEG monitoring, some neonates may be diagnosed with seizures based on suspicious movements, exposing them to unnecessary AED treatment. 18 The role of aEEG for seizure screening and monitoring of background evolution (including return to sleep wake cycling) merits additional study.…”

“…4,6 However, neonates with seizures during rewarming have been described, 6,8,[15][16][17] prompting many neonatal units to monitor neonates undergoing TH for the entire duration of cooling and rewarming. 4,5,18 This appears to be the current clinical practice in centers using cEEG to monitor neonates undergoing TH.…”

Potential biomarkers for neuroinflammation and neurodegeneration at short and long term after neonatal hypoxic-ischemic insult in rat

“…The susceptibility of the immature central nervous system (CNS) to HI is largely dependent on the temporal and regional status of critical developmental processes, as well as on the regulation of cerebral blood flow and metabolism [7]. The clinical diagnosis of neonatal HI and the assessment of disease severity mainly relies on the Sarnat score, brain CT (computed tomography) scans [8], MRI (magnetic resonance imaging), ultrasound diagnosis, and EEG (electroencephalogram) detection methods [9, 10]. Because of the influence of the progressive disease process and other factors, the Sarnat score is subjective, and other tests have limitations and double effectiveness in premature/newborn infants.…”

Amplitude-integrated electroencephalography for neonatal seizure detection. An electrophysiological point of view

“…There is controversy regarding the sensitivity and specificity of aEEG for electrographic detection of seizures, especially in comparison with conventional EEG [11][12][13][14][15][16][17][18][19][20][21][22][23] . But even with less sensitivity and specificity, the aEEG has numerous advantages: it allows for continuous monitoring over long periods of time; the simplicity of its interpretation does not require extensive training; and its use permits immediate detection and treatment of seizures.…”