Not all rhythmicities and periodicities in coma electroencephalography are fatal—When simplification becomes dangerous

Stefano, Pia De; Kaplan, Peter W.; Sutter, Raoul

doi:10.1111/epi.17319

Cited by 5 publications

(6 citation statements)

References 29 publications

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“…In scenarios with initial anesthesia which is not stopped before an EEG is performed during the initial clinical assessment after ROSC, the question whether such ongoing anesthesia within the early hours has the ability to successfully terminate seizures in case of undetected NCSE despite not strictly following the treatment guidelines for SE, including the establishment of an EEG burst-suppression pattern for 24–48 h as recommended [ 44 ], remains unanswered. A recent trial showing no benefit of aggressive antiseizure treatment of any rhythmic and periodic discharges in comatose post-CA patients still does not answer this question, since the targeted patients did not exclusively have SE as defined accordingly to the guidelines [ 21 , 29 ].…”

Section: Discussionmentioning

confidence: 99%

“…To what degree these proportions are influenced by detection and/or reporting biases remains unknown, but is likely to be the case as the lack of overt clinical signs or subtle presentation of NCSE can be missed without continuous electroencephalography (c-EEG) [ 20 ]. A recent trial found no benefits of aggressive treatment regarding outcome compared to standard care in post-CA comatose patients showing rhythmic and periodic discharges of any frequency on EEG (without limiting the study to EEG patterns reflecting SE [ 21 ]) performed within a median of 13.5 h following ROSC [ 22 ]. However, it seems plausible that unrecognized and untreated NCSE may cause subsequent neurologic injury and worsen outcome.…”

Section: Introductionmentioning

confidence: 99%

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Nonconvulsive status epilepticus following cardiac arrest: overlooked, untreated and misjudged

et al. 2022

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Aims Seizures and status epilepticus (SE) are detected in almost a third of the comatose cardiac arrest survivors. As the literature is quite exhaustive regarding SE with motor symptoms in those patients, little is known about nonconvulsive SE (NCSE). Our aim was to compile the evidence from the literature of the frequency and outcome of NCSE in adult patients remaining in coma after resuscitation. Methods The medical search PubMed was screened for most relevant articles reporting the emergence and outcome of NCSE in comatose post-resuscitated adult patients. Results We identified 11 cohort studies (four prospective observational, seven retrospective) including 1092 patients with SE in 29–96% and NCSE reported in 1–20%. EEG evaluation started at a median of 9.5 h (range 7.5–14.8) after cardiac arrest, during sedation and targeted temperature management (TTM). Favorable outcome after NCSE occurred in 24.5%. We found no study reporting EEG to detect or exclude NCSE in patients remaining in coma prior to the initiation of TTM and without sedation withing the first hours after ROSC. Discussion Studies on NCSE after ROSC are scarce and unsystematic, reporting favorable outcome in every fourth patient experiencing NCSE after ROSC. This suggests that NCSE is often overlooked and outcome after NCSE is not always poor. The low data quality does not allow firm conclusions regarding the effects of NCSE on outcome calling for further investigation. In the meantime, clinicians should avoid equating NCSE after ROSC with poor prognosis.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Nonconvulsive status epilepticus following cardiac arrest: overlooked, untreated and misjudged

et al. 2022

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“…41 As a marked difference, our subgroup consisted of patients with RSE after ABI, whereas in the recent multicenter trial, this was not specified. 42 While at first glance, these results were promising, a closer look showed that no surviving patient with any burst suppression had a GOS of 4–5 and the bias of “self-fulfilling prophecy” cannot be excluded. Likewise, there remains the possibility that the responsible clinicians treated more aggressively when they believed that individual patients may benefit.…”

Section: Discussionmentioning

confidence: 93%

Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus

et al. 2023

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Objective:To investigate the frequency of induced electroencephalographic (EEG) burst-suppression pattern during continuous intravenous anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE).Methods:Patients with RSE treated with anesthetics at a Swiss academic care center from 2011-2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst-suppression was categorized as incomplete burst-suppression (with ≥20% and <50% suppression proportion) or complete burst-suppression (with ≥50% suppression proportion). The frequency of induced burst-suppression, and association of burst-suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were endpoints.Results:We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst-suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst-suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity Index, RSE with motor symptoms, and the Status Epilepticus Severity Score (STESS) were identified as potential confounders in univariable comparisons between patients with and without any burst-suppression. Multivariable analyses revealed no associations between any burst-suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst-suppression was associated with persistent seizure termination (72% without vs. 29% with burst-suppression, p=0.004) and survival (50% vs. 14% p=0.005).Conclusions:In adult patients with RSE treated with IVAD, burst-suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival or return to premorbid neurologic function.

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“…There is uncertainty about which rhythmic and periodic patterns in post‐hypoxic patients reflect a “true” and reversible epileptic phenomenon. Patterns with a frequency <2.5 Hz may constitute a sign of severe and irreversible brain network injury as well as be related to metabolic disturbances which are commonly present in post‐hypoxic patients 35,36 . There is, however, evidence that GPDs can result from pathological activation of thalamo‐cortical networks similar to the generation of epileptiform discharges.…”

Section: Discussionmentioning

confidence: 99%

“…Patterns with a frequency <2.5 Hz may constitute a sign of severe and irreversible brain network injury as well as be related to metabolic disturbances which are commonly present in post‐hypoxic patients. 35 , 36 There is, however, evidence that GPDs can result from pathological activation of thalamo‐cortical networks similar to the generation of epileptiform discharges. Therefore, lower frequencies of GPDs may constitute a continuum between encephalopathy and status epilepticus.…”

Section: Discussionmentioning

confidence: 99%

Post‐hypoxic status epilepticus – A distinct subtype of status epilepticus with poor prognosis

Orav,

Bosque Varela,

Prüwasser

et al. 2023

Epileptic Disorders

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ObjectiveTo evaluate the clinical outcome of patients with possible and definitive post‐hypoxic status epilepticus (SE) and to describe the SE types in patients with definitive post‐hypoxic SE.MethodsPatients with definitive or possible SE resulting from hypoxic brain injury after cardiac arrest (CA) were prospectively recruited. Intermittent EEG was used for the diagnosis of SE according to clinical practice. Two raters blinded to outcome analyzed EEGs retrospectively for possible and definitive SE patterns and background features (frequency, continuity, reactivity, and voltage). Definitive SE was classified according to semiology (ILAE). Mortality and Cerebral Performance Categories (CPC) score were evaluated 1 month after CA.ResultsWe included 64 patients of whom 92% died. Among the survivors, only one patient had a good neurological outcome (CPC 1). No patient survived with a burst suppression pattern, low voltage, or electro‐cerebral silence in any EEG. Possible or definitive SE was diagnosed in a median of 47 h (IQR 39–72 h) after CA. EEG criteria for definitive electrographic SE were fulfilled in 39% of patients; in 38% – for electroclinical SE and in 23% – for ictal‐interictal continuum (IIC). The outcome did not differ significantly between the three groups. The only patient with good functional outcome belonged to the IIC group. Comatose non‐convulsive SE (NCSE) without subtle motor phenomenon occurred in 20% of patients with definitive electrographic SE and outcome was similar to other types of SE.SignificancePossible or definitive SE due to hypoxic brain injury is associated with poor prognosis. The outcome of patients with electrographic SE, electroclinical SE, and IIC did not differ significantly. Outcome was similar in patients with definitive electrographic SE with and without prominent motor features.

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Not all rhythmicities and periodicities in coma electroencephalography are fatal—When simplification becomes dangerous

Cited by 5 publications

References 29 publications

Nonconvulsive status epilepticus following cardiac arrest: overlooked, untreated and misjudged

Nonconvulsive status epilepticus following cardiac arrest: overlooked, untreated and misjudged

Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus

Post‐hypoxic status epilepticus – A distinct subtype of status epilepticus with poor prognosis

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