Prognostic Significance of Continuous EEG Monitoring in Patients With Poor-Grade Subarachnoid Hemorrhage

Claassen, Jan; Hirsch, Lawrence J.; Frontera, Jennifer A.; Fernandez, Andres; Schmidt, Michael; Kapinos, Gregory; Wittman, John; Connolly, E. Sander; Emerson, Ronald G.; Mayer, Stephan A.

doi:10.1385/ncc:4:2:103

Cited by 237 publications

(157 citation statements)

References 45 publications

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“…Reports have correlated periodic epileptiform discharges with seizures, 3 and poor outcome in patients with status epilepticus, 4 intracerebral hemorrhage, 5 and subarachnoid hemorrhage. 6 Lateralized periodic epileptiform discharges (also known as periodic lateralized epileptiform discharges [PLEDs]) have established associations with destructive focal lesions, usually acute, and seizures. 7 Generalized periodic discharges (GPDs) may result from thalamocortical pathway disruption associated with diffuse or multifocal cerebral dysfunction, or even systemic disease, but whether GPDs cause additional brain injury or if they are surrogate markers for the extent of brain injury remains unknown.…”

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confidence: 99%

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Generalized periodic discharges in the critically ill

et al. 2012

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Objective: Generalized periodic discharges are increasingly recognized on continuous EEG monitoring, but their relationship to seizures and prognosis remains unclear.Methods: All adults with generalized periodic discharges from 1996 to 2006 were matched 1:1 to controls by age, etiology, and level of consciousness. Overall, 200 patients with generalized periodic discharges were matched to 200 controls. Results:Mean age was 66 years (range 18-96); 56% were comatose. Presenting illnesses included acute brain injury (44%), acute systemic illness (38%), cardiac arrest (15%), and epilepsy (3%). A total of 46% of patients with generalized periodic discharges had a seizure during their hospital stay (almost half were focal), vs 34% of controls (p ϭ 0.014). Convulsive seizures were seen in a third of both groups. A total of 27% of patients with generalized periodic discharges had nonconvulsive seizures, vs 8% of controls (p Ͻ 0.001); 22% of patients with generalized periodic discharges had nonconvulsive status epilepticus, vs 7% of controls (p Ͻ 0.001). In both groups, approximately half died or were in a vegetative state, one-third had severe disability, and one-fifth had moderate to no disability. Excluding cardiac arrest patients, generalized periodic discharges were associated with increased mortality on univariate analysis (36.8% vs 26.9%; p ϭ 0.049). Multivariate predictors of worse outcome were cardiac arrest, coma, nonconvulsive status epilepticus, and sepsis, but not generalized periodic discharges. Conclusion:Generalized periodic discharges were strongly associated with nonconvulsive seizures and nonconvulsive status epilepticus. While nonconvulsive status epilepticus was independently associated with worse outcome, generalized periodic discharges were not after matching for age, etiology, and level of consciousness. Neurology ® 2012; 79:1951-1960

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“…In GPD patients, a past medical history of multiple medical problems also predicted worse outcome. Prior neurosurgery 14 (7) 10 (5) 24 (6) Single seizure 13 (6.5) 11 (5.5) 24 (6) Brain tumor 12 (6) 8 (4) 20 (5 …”

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Generalized periodic discharges in the critically ill

et al. 2012

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“…1211 Consequently, there has recently been a marked increase in the use of continuous EEG (cEEG) monitoring. [12][13][14][15] cEEG findings are often dynamic and have immediate management implications, thus requiring frequent review. Quantitative EEG tools are increasingly used to expedite data review, particularly in centers with large monitoring volumes.…”

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Spectrogram screening of adult EEGs is sensitive and efficient

Moura

Shafi

et al. 2014

Neurology

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Objective: Quantitatively evaluate whether screening with compressed spectral arrays (CSAs) is a practical and time-effective protocol for assisting expert review of continuous EEG (cEEG) studies in hospitalized adults.Methods: Three neurophysiologists reviewed the reported findings of the first 30 minutes of 118 cEEGs, then used CSA to guide subsequent review ("CSA-guided review" protocol). Reviewers viewed 120 seconds of raw EEG data surrounding suspicious CSA segments. The same neurophysiologists performed independent page-by-page visual interpretation ("conventional review") of all cEEGs. Independent conventional review by 2 additional, more experienced neurophysiologists served as a gold standard. We compared review times and detection rates for seizures and other pathologic patterns relative to conventional review.Results: A total of 2,092 hours of cEEG data were reviewed. Average times to review 24 hours of cEEG data were 8 (64) minutes for CSA-guided review vs 38 (617) minutes for conventional review (p , 0.005). Studies containing seizures required longer review: 10 (64) minutes for CSAguided review vs 44 (620) minutes for conventional review (p , 0.005). CSA-guided review was sensitive for seizures (87.3%), periodic epileptiform discharges (100%), rhythmic delta activity (97.1%), focal slowing (98.7%), generalized slowing (100%), and epileptiform discharges (88.5%).

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“…After SAH, prophylactic phenytoin therapy might reasonably be given to prevent a seizure and the potential attendant increase in BP and risk of aneurysm rebleeding. Subarachnoid hemorrhage may be complicated by nonconvulsive seizures or status epilepticus (107), and routine EEG monitoring is often obtained in patients with a depressed level of consciousness. Like IPH, however, routine anticonvulsant medication use is probably not advisable.…”

Section: Specific Management Of Aneurysmal Subarachnoid Hemorrhagementioning

confidence: 99%

Intracranial Hemorrhage

Naidech

2011

Am J Respir Crit Care Med

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Intracranial hemorrhage is a life-threatening condition, the outcome of which can be improved by intensive care. Intracranial hemorrhage may be spontaneous, precipitated by an underlying vascular malformation, induced by trauma, or related to therapeutic anticoagulation. The goals of critical care are to assess the proximate cause, minimize the risks of hemorrhage expansion through blood pressure control and correction of coagulopathy, and obliterate vascular lesions with a high risk of acute rebleeding. Simple bedside scales and interpretation of computed tomography scans assess the severity of neurological injury. Myocardial stunning and pulmonary edema related to neurological injury should be anticipated, and can usually be managed. Fever (often not from infection) is common and can be effectively treated, although therapeutic cooling has not been shown to improve outcomes after intracranial hemorrhage. Most functional and cognitive recovery takes place weeks to months after discharge; expected levels of functional independence (no disability, disability but independence with a device, dependence) may guide conversations with patient representatives. Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage. Future directions include refining the use of bedside neuromonitoring (electroencephalogram, invasive monitors), novel approaches to reduce intracranial hemorrhage expansion, minimizing vasospasm, and refining the assessment of quality of life to guide rehabilitation and therapy.

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Prognostic Significance of Continuous EEG Monitoring in Patients With Poor-Grade Subarachnoid Hemorrhage

Cited by 237 publications

References 45 publications

Generalized periodic discharges in the critically ill

Generalized periodic discharges in the critically ill

Spectrogram screening of adult EEGs is sensitive and efficient

Intracranial Hemorrhage

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