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Epileptiform Activity in Neurocritical Care Patients

Published online by Cambridge University Press:  02 December 2014

Andreas H. Kramer ,
Nathalie Jette ,
Neelan Pillay ,
Paolo Federico  and
David A. Zygun
Andreas H. Kramer*
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Nathalie Jette
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Neelan Pillay
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Paolo Federico
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
David A. Zygun
Affiliation:
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
*
Departments of Critical Care Medicine & Clinical Neurosciences, Foothills Medical Center, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada. Email: Andreas.Kramer@AlbertaHealth Services.ca
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Abstract

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Background:

Non-convulsive seizures have been reported to be common in neurocritical care patients. Many jurisdictions do not have sufficient resources to enable routine continuous electroencephalography (cEEG) and instead use primarily intermittent EEG, for which the diagnostic yield remains uncertain. Determining risk factors for epileptiform activity and seizures could help identify patients who might particularly benefit from EEG monitoring.

Methods:

We performed a cohort study involving neurocritical care patients with admission Glascow Coma Scale (GCS) scores =≤ 12, who underwent ≥ 1 EEG. EEGs were reviewed for presence of interictal discharges, periodic epileptiform discharges (PEDs), and seizures. Multivariate analysis was used to identify predictors of these findings and to describe their prognostic implications.

Results:

393 patients met inclusion criteria. 34 underwent cEEG, usually because epileptiform activity was first detected on a routine EEG. The prevalence of PEDs or electrographic seizures was 13%, and was highest with anoxic encephalopathy and central nervous system infections. Other independent predictors for epileptiform activity included a history of convulsive seizure(s), increasing age, deeper coma, and female gender. Although patients with epileptiform activity had higher mortality, this association disappeared after adjustment for confounders.

Conclusion:

Approximately 7-8 neurocritical care patients must undergo intermittent EEG monitoring in order to diagnose one with PEDs or seizures. The predictors we identified could potentially help guide use of resources. Repeated intermittent studies, or cEEG, should be considered in patients with multiple risk factors, or when interictal discharges are identified on an initial EEG. It remains unclear whether aggressive prevention and treatment of electrographic seizures improves neurologic outcomes.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 39 , Issue 3 , May 2012 , pp. 328 - 337
Copyright
Copyright © The Canadian Journal of Neurological 2012

References

1Suarez, J.Outcome in neurocritical care: Advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med. 2006;34:S232–8.Google Scholar
2Annegers, JF, Grabow, JD, Groover, RV, Laws, ER, Elveback, LR, Kurland, LT.Seizures after head trauma: a population study. Neurology. 1980;30:683–9.Google Scholar
3Butzkueven, H, Evans, AH, Pitman, A, et al.Onset seizures independently predict poor outcome after subarachnoid hemorrhage. Neurology. 2000;55: 1315–20.CrossRefGoogle ScholarPubMed
4Berger, AR, Lipton, RB, Lesser, ML, Lantos, G, Portenoy, RK.Early seizures following intracerebral hemorrhage. Neurology. 1988; 38:1363–5.Google Scholar
5Arboix, A, Garcia-Eroles, L, Massons, JB, Oliveres, M, Comes, E.Predictive factors of early seizures after acute cerebrovascular disease. Stroke. 1997;28:1590–4.Google Scholar
6Zoons, E, Weisfelt, M, de Gans, J, et al.Seizures in adults with bacterial meningits. Neurology. 2008;70:2109–15.Google Scholar
7Vespa, PM, Nuwer, MR, Nenov, V, et al.Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as deteted by continuous electroencephalographic monitoring. J Neurosurg. 1999;91:750–60.Google Scholar
8Vespa, PM, O’Phelan, K, Shaw, M, et al.Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology. 2003;60:1441–6.Google Scholar
9Claassen, J, Jette, N, Chum, F, et al.Electrographic seizures and periodic discharges after intracerebral hemorrhage. Neurology. 2007;69:1356–65.Google Scholar
10Young, GB, Jordan, KG, Doig, GS.An assessment of nonconvulsive seizures in the intensive care unit using continuous EEG monitoring: An investigation of variables associated with mortality. Neurology. 1996;47:83–9.Google Scholar
11Young, GB, Doig, GS.Continuous EEG monitoring in comatose intensive care patients. Neurocrit Care. 2005;2:5–10.Google Scholar
12Rossetti, AO, Logroscino, G, Liaudet, L, et al.Status epilepticus. An independent outcome predictor after cerebral anoxia. Neurology. 2007;69:255–60.CrossRefGoogle ScholarPubMed
13Claassen, J, Mayer, SA, Kowalski, RG, Emerson, RG, Hirsch, LJ.Detection of elctrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62:1743–8.CrossRefGoogle ScholarPubMed
14Young, JD, Goldfrad, C, Rowan, K.Development and testing of a hierachical method to code the reason for admission to intensive care units: the ICNARC Coding Method. Br J Aneaesth. 2001; 87:543–8.Google Scholar
15Maas, AIR, Stocchetti, N, Bullock, R.Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7:728–41CrossRefGoogle ScholarPubMed
16Report of World Federation of Neurological Surgeons committee on a universal subarachnoid hemorrhage grading scale. J Neurosurg. 1988;68:985–6.Google Scholar
17Hemphill, JC, Bonovich, DC, Besmertis, L, Manley, GT, Johnston, SC, Tuhrim, S.The ICH Score: A simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.Google Scholar
18Knaus, WA, Draper, EA, Wagner, DP, Zimmerman, JE.APACHE II: a severity of disease classification system. Crit Care Med. 1985; 13:818–29.Google Scholar
19Zygun, D, Berthiaume, L, Laupland, K, Kortbeek, J, Doig, C.SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study. Crit Care. 2006;10:R115.CrossRefGoogle ScholarPubMed
20Anonymous. Clinical neurophysiology. In: Ahlskog, JE, Aksamit, AJ, Aronson, AE, editors. Clinical examination in neurology. St. Louis: Mayo Foundation for Medical Education and Research. Mosby Year Book; 1991. p.354–451.Google Scholar
21Hirsch, LJ, Brenner, RP, Drislane, FW, et al.The ACNS Subcommittee on Research Terminology for Continuous EEG Monitoring: Proposed Standardized Terminology for Rhythmic and Periodic EEG Patterns Encountered in Critically Ill Patients. J Clin Neurophys. 2005;22:128–35.Google Scholar
22Lowenstein, DH, Bleck, T, Macdonald, RL.It’s time to revise the definition of status epilepticus. Epilepsia. 1999;40:120–2.CrossRefGoogle ScholarPubMed
23Temkin, NR, Dikmen, SS, Wilensky, AJ, Keihm, J, Chabal, S, Winn, HR.A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990;323: 497–502.CrossRefGoogle ScholarPubMed
24Bederson, JB, Connolly, ES Jr, Batjer, HH, et al.Guidelines for the management of aneurismal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025.Google Scholar
25Morgenstern, LB, Hemphill, JC 3rd, Anderson, C, et al.Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41: 2108–29.Google Scholar
26Carrera, E, Claassen, J, Oddo, M, Emerson, RG, Mayer, SA, Hirsch, LJ.Continuous electroencephalographic monitoring in critically ill patients with central nervous system infection. Arch Neurol. 2008;65:1612–8.Google Scholar
27Brenner, RP, Schaul, N.Periodic EEG patterns: classification, clinical correlation and pathophysiology. J Clin Neurophysiol. 1990;7:249–67.Google Scholar
28Murray, GD, Bucher, I, McHugh, GS, et al.Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:329–37.Google Scholar
29Rosengart, AJ, Schultheiss, KE, Tolentino, J, Macdonald, RL.Prognostic factors for outcome in patients with aneurismal subarachnoid hemorrhage. Stroke. 2007;38:2315–21.Google Scholar
30van de Beek, D, de Gans, J, Spanjaard, L, Weisfelt, M, Reitsma, JB, Vermeulen, M.Clinical features and prognostic factors in adults with bacteria meningitis. N Engl J Med. 2004;351:1849–59.Google Scholar
31Steiner, T, Mendoza, G, De Georgia, M, Schellinger, P, Holle, R, Hacke, W.Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28: 711–15.Google Scholar
32Olivecrona, M, Zetterlund, B, Rodling-Wahlstrom, M, Naredi, S, Koskinen, LD.Absence of electroencephalographic seizure activity in patients treated for head injury with an intracranial pressure-targeted therapy. J Neurosurg. 2009;110:300–5.Google Scholar
33Alroughani, R, Javidan, M, Qasem, A, Alotaibi, N.Non-convulsive status epilepticus; the rate of occurrence in a general hospital. Seizure. 2009;18:38–42.Google Scholar
34Varelas, PN, Hacein-Bey, L, Hether, T, Terranova, B, Spanaki, MV.Emergent electroencephalogram in the intensive care unit: indications and diagnostic yield. Clin EEG Neurosci. 2004;35: 173–80.Google Scholar
35Vagnerova, K, Koerner, IP, Hurn, PD.Gender and the injured brain. Anesth Analg. 2008;107:201–14.Google Scholar
36Wigginton, JG, Pepe, PE, Idris, AH.Rationale for routine and immediate administration of intravenous estrogen for all critically ill and injured patients. Crit Care Med. 2010;38:S620–9.Google Scholar
37Veliskova, J, De Jesus, G, Kaur, R, Velisek, L.Females, their estrogens and seizures. Epilepsia. 2010;51:141–4.Google Scholar
38Frye, CA.Effects and mechanisms of progestogens and androgens in ictal activity. Epilepsia. 2010;51:135–40.Google Scholar
39Fraser, DD, Hutchison, JS.Estrogen therapy after traumatic brain injury: time for clinical trials? Crit Care Med. 2009;37:3181–2.Google Scholar
40Wagner, J, Dusick, JR, McArthur, DL, et al.Acute gonadotroph and somatotroph hormonal suppression after traumatic brain injury. J Neurotrauma. 2010;27:1007–19.Google Scholar
41Wright, DW, Kellermann, AL, Hertzberg, VS, et al.ProTECT: A randomized clinical trial of progesterone for acute traumatic brain injury. Ann Emerg Med. 2007;49:391–402.Google Scholar
42Xiao, G, Wei, J, Yan, W, Wang, W, Lu, Z.Improved outcomes from the administration of progesterone for patients with acute severe traumatic brain injury: a randomized controlled trial. Crit Care. 2008;12:1–10.Google Scholar
43Vespa, PM, Miller, C, McArthur, D, et al.Nonconvulsive electrographic seizures after traumatic brain injury result in a delayed, prolonged increase in intracranial pressure and metabolic crisis. Crit Care Med. 2007;35:2830–6.Google Scholar
44Szabo, K, Poepel, A, Pohlmann-Eden, B, et al.Diffusion-weighted and perfusion MRI demonstrates parenchymal changes in complex partial status epilepticus. Brain. 2005;128:1369–76.Google Scholar
45Vespa, PM, McArthur, DL, Xu, Y, et al.Nonconvulsive seizures after traumatic brain injury are associated with hippocampal atrophy. Neurology. 2010;75:792–8.CrossRefGoogle ScholarPubMed
46DeGiorgio, CM, Heck, CN, Rabinowicz, AL, Gott, PS, Smith, T, Correale, J.Serum neuron-specific enolase in the major subtypes of status epiletpicus. Neurology. 1999;52:746–9.Google Scholar
47Correale, J, Rabinowicz, AL, Heck, CN, Smith, TD, Loskota, WJ, DeGiorgio, CM.Status epilepticus increases CSF levels of neuron-specific enolase and alters the blood-brain barrier. Neurology. 1998;50:1388–91.Google Scholar
48Badawy, RA, Pillay, N, Jette, N, Wiebe, S, Federico, P.A blinded comparison of continuous versus sampled review of video-EEG monitoring data. Clin Neurophysiol. 2011;122:1086–90.Google Scholar
49Young, GB, McLachlan, RS, Kreeft, JH, Demelo, JD.An electroencephalographic classification for coma. Can J Neurol Sci. 1997;24:320–5.Google Scholar
50Ronner, HE, Ponten, SC, Stam, CJ, Uitdehaag, BM.Inter-observer variability of the EEG diagnosis of seizures in comatose patients. Seizure. 2009;18:257–63.Google Scholar