Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome

Intracerebral hemorrhage and delirium symptoms. Length of stay, function, and quality of life in a 114-patient cohort

RATIONALE

The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear.

OBJECTIVES

To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage.

METHODS

We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months.

MEASUREMENTS AND MAIN RESULTS

Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P = 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P = 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up.

CONCLUSIONS

After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL.

Seizure prophylaxis in neurocritical care: a review of evidence-based support

Seizures are a well-described complication of acute brain injury and neurosurgery. Antiepileptic drugs (AEDs) are frequently utilized for seizure prophylaxis in neurocritical care patients. In this review, the Neurocritical Care Society Pharmacy Section describes the evidence associated with the use of AEDs for seizure prophylaxis in patients with intracerebral tumors, traumatic brain injury, aneurysmal subarachnoid hemorrhage, craniotomy, ischemic stroke, and intracerebral hemorrhage. Clear evidence indicates that the short-term use of AEDs for seizure prophylaxis in patients with traumatic brain injury and aneurysmal subarachnoid hemorrhage may be beneficial; however, evidence to support the use of AEDs in other disease states is less clear.

Continuous electroencephalography in a surgical intensive care unit

PURPOSE

Our aim was to investigate the prevalence, risk factors, and impact on outcome of nonconvulsive seizures (NCSz), nonconvulsive status epilepticus (NCSE), and periodic epileptiform discharges (PEDs) in surgical intensive care unit (SICU) patients with continuous electroencephalography (cEEG) monitoring.

METHODS

This was a retrospective study of SICU patients who underwent cEEG monitoring for altered mental status over a 6-year period. We report the frequency of NCSz (including NCSE) and PEDs on cEEG. The primary outcome was death or severe disability at hospital discharge. Multivariable logistic regression was used to identify whether NCSz (including NCSE) and PEDs were independently associated with poor outcome (death, vegetative state or severe disability).

RESULTS

Of 154 patients, the mean age was 64 ± 14 years old, and 40% were women. The majority of patients were admitted following abdominal surgery (36%) and liver transplantation (24%). Sepsis developed in 100 (65%) patients. Sixteen percent (n = 24) had NCSz [including 5% (N = 8) with NCSE], and 29% (N = 45) had PEDs. All eight patients with NCSE were septic. Clinical seizures prior to cEEG and coma were more common among patients who developed NCSz or NCSE compared to patients without NCSz or NCSE (70 vs. 27%; p < 0.01; 75 vs. 52%; p = 0.046 and 63 vs. 34%; p = 0.09, respectively). NCSzs (including NCSE) were independently associated with poor outcome (20 vs. 3%, OR 10.4, 95% CI 1.0-53.7; p = 0.039).

CONCLUSION

In this retrospective study of SICU patients with cEEG monitoring for altered mental status, NCSz and periodic discharges were frequent and NCSz were independently associated with poor outcome. NCSz were more common when clinical seizures occurred before cEEG.

Ethosuximide and phenytoin dose-dependently attenuate acute nonconvulsive seizures after traumatic brain injury in rats

Acute seizures frequently occur following severe traumatic brain injury (TBI) and have been associated with poor patient prognosis. Silent or nonconvulsive seizures (NCS) manifest in the absence of motor convulsion, can only be detected via continuous electroencephalographic (EEG) recordings, and are often unidentified and untreated. Identification of effective anti-epileptic drugs (AED) against post-traumatic NCS remains crucial to improve neurological outcome. Here, we assessed the anti-seizure profile of ethosuximide (ETX, 12.5-187.5 mg/kg) and phenytoin (PHT, 5-30 mg/kg) in a spontaneously occurring NCS model associated with penetrating ballistic-like brain injury (PBBI). Rats were divided between two drug cohorts, PHT or ETX, and randomly assigned to one of four doses or vehicle within each cohort. Following PBBI, NCS were detected by continuous EEG monitoring for 72 h post-injury. Drug efficacy was evaluated on NCS parameters of incidence, frequency, episode duration, total duration, and onset latency. Both PHT and ETX attenuated NCS in a dose-dependent manner. In vehicle-treated animals, 69-73% experienced NCS (averaging 9-10 episodes/rat) with average onset of NCS occurring at 30 h post-injury. Compared with control treatment, the two highest PHT and ETX doses significantly reduced NCS incidence to 13-40%, reduced NCS frequency (1.8-6.2 episodes/rat), and delayed seizure onset: <20% of treated animals exhibited NCS within the first 48 h. NCS durations were also dose-dependently mitigated. For the first time, we demonstrate that ETX and PHT are effective against spontaneously occurring NCS following PBBI, and suggest that these AEDs may be effective at treating post-traumatic NCS.

Protocol for Seizure Prophylaxis following Intracerebral Hemorrhage Study (SPICH): A Randomized, Double-Blind, Placebo-Controlled Trial of Short-Term Sodium Valproate Prophylaxis in Patients with Acute Spontaneous Supratentorial Intracerebral Hemorrhage

Rationale

Seizures after intracerebral hemorrhage are a common complication and may adversely affect neurological outcome. However, studies are inadequate on the utility of prophylactic anticonvulsant therapy in patients with hemorrhagic stroke, and the results remains controversial.

Aims

This study aims to determine if short-duration sodium valproate prevents seizure onset or improves the survival and neurological outcome in adults after acute spontaneous supratentorial intracerebral hemorrhage.

Design

In this randomized, double blinded, placebo-controlled trial, 258 patients meeting the inclusion criteria will be enrolled in the Department of Neurosurgery, West China Hospital. In addition to standard care, patients will be randomly assigned to receive seven-day prophylaxis of sodium valproate 500 mg daily (alternatively 400 mg daily by intravenous infusion in 250 ml 0·9% normal saline) or matching placebo. Patients will be followed up at seven-days, 3, 6, and 12 months.

Study outcomes

The primary outcomes are early (≤7 days) and late onset seizures (>7 days). Secondary outcomes include midline shift, enlargement of hematoma, death (all cause), adverse effects, and functional outcome assessed by Glasgow Outcome Scale and modified Rankin Scale.

Discussion

Given the lack of evidence for seizure prophylaxis in patients with acute supratentorial intracerebral hemorrhage, randomized controlled trials are desperately needed. The results from our study are believed to directly influence future prophylactic anticonvulsant therapy of intracerebral hemorrhage.

Seizures and antiepileptic drugs in patients with spontaneous intracerebral hemorrhages

PURPOSE

Patients with intracerebral hemorrhage (ICH) are often initiated on antiepileptic drugs without a clear indication. We compared the percentage of patients with spontaneous ICH who had seizures at onset or during hospitalization, and examined empiric use of antiepileptic drugs (AEDs) in these patients in 2 cohorts 10 years apart.

METHODS

Using a clinical data registry at a tertiary care adult hospital, we retrospectively selected admissions for spontaneous ICH between 1/1/99-12/31/00 (Cohort A, n=30) and 1/1/09-12/31/10 (Cohort B, n=108). Clinical, neurophysiological and radiological data were collected in both cohorts.

RESULTS

In Cohorts A and B respectively, AEDs were started in 53.3% and 50.0%, and continued on discharge in 50.0% and 20.4% of patients; 86.6% and 59.1% of patients discharged on AEDs did not have a clinical/electrographic seizure or epileptiform EEG findings. Seizures occurred in 6.6% and 13.0% in Cohorts A and B respectively. The presence of a seizure at presentation (p=0.01) and during hospitalization (p=0.02) were predictors for continuing AED on discharge.

CONCLUSION

In both cohorts, a significant number of patients were discharged on AEDs without a clear indication, though there is a change in practice between the two cohorts.

Diagnostic yield of electroencephalography in a general inpatient population

OBJECTIVE

To determine the frequency and clinical predictors of seizures and markers of epileptiform activity in a noncritically ill general inpatient population.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients 18 years and older who underwent inpatient electroencephalography (EEG) between January 1, 2005, and December 31, 2010, for an indication of spells or altered mental status. The EEGs and reports were reviewed for ictal activity, interictal epileptiform abnormalities, and nonepileptiform abnormalities. Demographic and clinical data were gathered from the electronic medical record to determine seizure predictors.

RESULTS

Of 2235 patients screened, 1048 met the inclusion criteria, of which 825 (78.7%) had an abnormal EEG finding. Seizures occurred in 78 of 1048 patients (7.4%), and interictal epileptiform discharges were noted in 194 of 1048 patients (18.5%). An intracranial mass and spells as the indication for the EEG were independently associated with the group of patients experiencing seizures in a multivariate logistic regression model (adjusted for age, sex, EEG indication, intracranial mass, stroke, and history of epilepsy). Ninety-seven percent of patients (69 of 71) experienced their first seizure within 24 hours of monitoring, and the presence of seizures was associated with a lower likelihood of being discharged (odds ratio, 0.45; 95% CI, 0.27-0.76).

CONCLUSION

Seizures occurred at a high frequency in hospitalized patients with spells and altered mental status. The EEG may be an underused investigative tool in the hospital with the potential to identify treatable causes of these common disorders.

Levetiracetam use in the critical care setting

Intravenous (IV) levetiracetam (LEV) is currently approved as an alternative or replacement therapy for patients unable to take the oral form of this antiepileptic drug (AED). The oral form has Food and Drug Administration (FDA) indications for adjunctive therapy in the treatment of partial onset epilepsy ages 1 month or more, myoclonic seizures associated with juvenile myoclonic epilepsy starting with the age of 12 and primary generalized tonic-clonic seizures in people 6 years and older. Since the initial introduction, oral and IV LEV has been evaluated in various studies conducted in the critical care setting for the treatment of status epilepticus, stroke-related seizures, seizures following subarachnoid or intracerebral hemorrhage, post-traumatic seizures, tumor-related seizures, and seizures in critically ill patients. Additionally, studies evaluating rapid infusion of IV LEV and therapeutic monitoring of serum LEV levels in different patient populations have been performed. In this review we present the current state of knowledge on LEV use in the critical care setting focusing on the IV uses and discuss future research needs.

EEG and epilepsy monitoring

PURPOSE OF REVIEW

This article reviews the utility of EEG and prolonged video-EEG telemetry in the diagnosis and management of a patient with epilepsy.

RECENT FINDINGS

The EEG can be the most helpful test to determine a diagnosis of epilepsy; it can also distinguish focal and generalized neurophysiologic correlates of epilepsy. Furthermore, when paired with video monitoring, EEG can not only define epileptic and nonepileptic events but also aid in localization of seizures in patients with epilepsy. Finally, when history and other imaging modalities are considered with the EEG, the epileptic syndrome can usually be defined and the treatment can be focused. In critically ill patients, continuous EEG monitoring can define subclinical seizures, although a variety of periodic patterns may also be identified.

SUMMARY

EEG is an invaluable tool in the diagnosis and management of a patient with epilepsy, and continuous EEG monitoring is useful in identifying subclinical seizures and nonconvulsive status epilepticus in critically ill patients.

Multimodality monitoring in the neurointensive care unit: a special perspective for patients with stroke

Multimodality monitoring (MMM) is a recently developed method that aids in understanding real-time brain physiology. Early detection of physiological disturbances is possible with the help of MMM, which allows identification of underlying causes of deterioration and minimization of secondary brain injury (SBI). MMM is especially helpful in comatose patients with severe brain injury because neurological examinations are not sensitive enough to detect SBI. The variables frequently examined in MMM are hemodynamic parameters such as intracranial pressure, cerebral perfusion pressure, and mean arterial pressure; brainspecific oxygen tension; markers for brain metabolism including glucose, lactate, and pyruvate levels in brain tissue; and cerebral blood flow. Continuous electroencephalography can be performed, if needed. The majority of SBIs stem from brain tissue hypoxia, brain ischemia, and seizures, which lead to a disturbance in brain oxygen levels, cerebral blood flow, and electrical discharges, all of which are easily detected by MMM. In this review, we discuss the clinical importance of physiological variables as well as the practical applicability of MMM in patients with stroke.

Continuous electroencephalographic monitoring in critically ill patients: indications, limitations, and strategies

OBJECTIVE

Continuous electroencephalography as a bedside monitor of cerebral activity has been used in a range of critically ill patients. This review compiles the indications, limitations, and strategies for continuous electroencephalography in the ICU.

DATA SOURCE

The authors searched the electronic MEDLINE database.

STUDY SELECTION AND DATA EXTRACTION

References from articles of special interest were selected.

DATA SYNTHESIS AND CONCLUSION

Electroencephalographically-defined suppression is routinely used as the basis for titration of pharmacologic therapy in refractory status epilepticus and intracranial hypertension. The increasing use of continuous electroencephalography reveals a clinically underappreciated burden of epileptiform and epileptic activity in patients with primary acute neurologic disorders, and also in critically ill patients with acquired encephalopathy. Status epilepticus is reported with continuous electroencephalography in 1% to 10% of patients with ischemic stroke, 8% to 14% with traumatic brain injury, 10% to 14% with subarachnoid hemorrhage, 1% to 21% with intracerebral hemorrhage, and 30% of patients following cardiorespiratory arrest. These figures underscore the importance of continuous electroencephalography in the critically ill. The interpretation of continuous electroencephalography in the ICU is challenged by electroencephalography artifacts and the frequent subtle differences between ictal and interictal patterns.

Confounding by indication in retrospective studies of intracerebral hemorrhage: antiepileptic treatment and mortality

INTRODUCTION

Intracerebral hemorrhage (ICH) is a highly fatal disease with few proven treatments. Data to guide clinician decisions for therapies, including antiepileptic drugs (AED), are limited. Published studies on AED treatment in ICH have provided conflicting results. We investigated the effect of AED treatment on 90-day mortality after ICH in a large prospectively ascertained cohort.

METHODS

We conducted a retrospective analysis of a prospectively assembled cohort of patients with ICH in the supratentorial regions, comparing 90-day mortality and modified Rankin Score among 543 patients treated with AED during hospitalization and 639 AED-free ICH. Supratentorial ICH location was categorized as lobar or deep hemispheric.

RESULTS

Multivariate analysis demonstrated an association between AED treatment and reduced 90-day mortality in supratentorial ICH (OR = 0.62, 95 % CI 0.42-0.90, p = 0.01) and the subset of lobar ICH (OR = 0.49, 95 % CI 0.25-0.96, p = 0.04). When analyses were restricted to subjects surviving longer than 5 days from ICH, however, no association between AED treatment and a 90-day outcome, regardless of hemorrhage location (all p > 0.15), was detected, despite more than adequate power to detect the originally observed association.

CONCLUSION

These results suggest that AED treatment in acute ICH is not associated with 90-day mortality or outcome and that any detected association could arise by confounding by indication, in which the most severely affected patients are those in whom AEDs are prescribed. They provide a cautionary example of the limitations of drawing conclusions about treatment effects from observational data.

Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM

OBJECTIVES

Recommendations for EEG monitoring in the ICU are lacking. The Neurointensive Care Section of the ESICM assembled a multidisciplinary group to establish consensus recommendations on the use of EEG in the ICU.

METHODS

A systematic review was performed and 42 studies were included. Data were extracted using the PICO approach, including: (a) population, i.e. ICU patients with at least one of the following: traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, stroke, coma after cardiac arrest, septic and metabolic encephalopathy, encephalitis, and status epilepticus; (b) intervention, i.e. EEG monitoring of at least 30 min duration; (c) control, i.e. intermittent vs. continuous EEG, as no studies compared patients with a specific clinical condition, with and without EEG monitoring; (d) outcome endpoints, i.e. seizure detection, ischemia detection, and prognostication. After selection, evidence was classified and recommendations developed using the GRADE system.

RECOMMENDATIONS

The panel recommends EEG in generalized convulsive status epilepticus and to rule out nonconvulsive seizures in brain-injured patients and in comatose ICU patients without primary brain injury who have unexplained and persistent altered consciousness. We suggest EEG to detect ischemia in comatose patients with subarachnoid hemorrhage and to improve prognostication of coma after cardiac arrest. We recommend continuous over intermittent EEG for refractory status epilepticus and suggest it for patients with status epilepticus and suspected ongoing seizures and for comatose patients with unexplained and persistent altered consciousness.

CONCLUSIONS

EEG monitoring is an important diagnostic tool for specific indications. Further data are necessary to understand its potential for ischemia assessment and coma prognostication.

Seizures and the neurosurgical intensive care unit

The cause of seizures in the neurosurgical intensive care unit (NICU) can be categorized as emanating from either a primary brain pathology or from physiologic derangements of critical care illness. Patients are typically treated with parenteral antiepileptic drugs. For early onset ICU seizures that are easily controlled, data support limited treatment. Late seizures have a more ominous risk for subsequent epilepsy and should be treated for extended periods of time or indefinitely. This review ends by examining the treatment algorithms for simple seizures and status epilepticus and the role newer antiepileptic use can play in the NICU.

Nefiracetam attenuates post-ischemic nonconvulsive seizures in rats and protects neuronal cell death induced by veratridine and glutamate

AIMS

Stroke patients are at a high risk of developing post-ischemic seizures and cognitive impairment. Nefiracetam (NEF), a pyrrolidone derivative, has been shown to possess both anti-epileptic and cognitive-enhancing properties. In this study the anti-seizure effects of NEF were evaluated in a rat model of post-ischemic nonconvulsive seizures (NCSs). Its potential mechanisms were investigated in neuronal cell culture assays of neurotoxicity associated with ischemic brain injury and epileptogenesis.

MAIN METHODS

In the in vivo study, rats received 24h permanent middle cerebral artery occlusion. NEF was administered intravenously either at 15 min post-injury but prior to the first NCS event (30 mg/kg, pre-NCS treatment) or immediately after the first NCS occurred (30 or 60 mg/kg, post-NCS treatment). In the in vitro study, neuronal cell cultures were exposed to veratridine or glutamate and treated with NEF (1-500 nM).

KEY FINDINGS

The NEF pre-NCS treatment significantly reduced the NCS frequency and duration, whereas the higher NEF dose (60 mg/kg) was required to achieve similar effects when given after NCS occurred. The NEF treatment also dose-dependently (5-500 nM) protected against neuronal cell death induced by veratridine as measured by MTT cell viability assay, but higher doses (250-500 nM) were required against glutamate toxicity.

SIGNIFICANCE

The anti-seizure property of NEF was demonstrated in a clinically relevant rat model of post-ischemic NCS. The preferential effects of NEF against in vitro veratridine toxicity suggest the involvement of its modulation of sodium channel malfunction. Future studies are warranted to study the mechanisms of NEF against ischemic brain injury and post-ischemic seizures.

Similarities and differences of acute nonconvulsive seizures and other epileptic activities following penetrating and ischemic brain injuries in rats

The similarities and differences between acute nonconvulsive seizures (NCS) and other epileptic events, for example, periodic epileptiform discharges (PED) and intermittent rhythmic delta activities (IRDA), were characterized in rat models of penetrating and ischemic brain injuries. The NCS were spontaneously induced by either unilateral frontal penetrating ballistic-like brain injury (PBBI) or permanent middle cerebral artery occlusion (pMCAO), and were detected by continuous electroencephalogram (EEG) monitoring begun immediately after the injury and continued for 72 h or 24 h, respectively. Analysis of NCS profiles (incidence, frequency, duration, and time distribution) revealed a high NCS incidence in both injury models. The EEG waveform expressions of NCS and PED exhibited intrinsic variations that resembled human electrographic manifestations of post-traumatic and post-ischemic ictal and inter-ictal events, but these waveform variations were not distinguishable between the two types of brain injury. However, the NCS after pMCAO occurred more acutely and intensely (latency=0.6 h, frequency=25 episodes/rat) compared with the PBBI-induced NCS (latency=24 h, frequency=10 episodes/rat), such that the most salient features differentiating post-traumatic and post-ischemic NCS were the intensity and time distribution of the NCS profiles. After pMCAO, nearly 50% of the seizures occurred within the first 2 h of injury, whereas after PBBI, NCS occurred sporadically (0-5%/h) throughout the 72 h recording period. The PED were episodically associated with NCS. By contrast, the IRDA appeared to be independent of other epileptic events. This study provided comprehensive comparisons of post-traumatic and post-ischemic epileptic profiles. The identification of the similarities and differences across a broad spectrum of epileptic events may lead to differential strategies for post-traumatic and post-stroke seizure interventions.

Survey of prophylactic antiseizure drug use for non-traumatic intracerebral hemorrhage

OBJECTIVE

Prophylactic antiseizure drugs (PAD) are commonly prescribed for non-traumatic intracerebral hemorrhage (ICH) despite limited evidence for this indication. We sought to determine the current prescribing patterns of the use of a PAD for ICH.

METHODS

A 36-item survey was distributed to physicians who manage ICH patients soliciting details of PAD prescription in their practice.

RESULTS

A total of 199 physicians responded to the survey, all of who manage 50 or more ICH patients per year. The respondents were neurologists (32%), neurosurgeons (11%), and intensivists (57%) in academia (69%) and private practice (31%). Prophylactic antiseizure drugs prescriptions used: never (33%), 1-33% (35%), 34-66% (14%), 67-99% (9%) of the time, or always (9%). Most respondents performed electroencephalographic and serum level monitoring in at least some patients. Levetiracetam was used most often (60%), followed by fosphenytoin (37%), for a usual duration of days (36%), weeks (47%), or months (17%). Prophylactic antiseizure drugs prescription varied by patient characteristics and physician specialty. Perception of physician community consensus regarding PAD use for ICH among respondents ranged from strongly (7%) or weakly (23%) against the practice, to a fairly equal division of opinion (41%), to weakly (27%) or strongly (4%) in favor of the practice.

CONCLUSIONS

We found variability of multiple aspects of the current prescribing patterns and opinions regarding the use of a PAD for ICH. This variability is likely secondary to insufficient data. Clinical equipoise exists for this issue, and controlled trials would be both justified and useful.

Diagnostic yield of electroencephalography in a general inpatient population

OBJECTIVE

To determine the frequency and clinical predictors of seizures and markers of epileptiform activity in a non-critically ill general inpatient population.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients 18 years and older who underwent inpatient electroencephalography (EEG) between January 1, 2005, and December 31, 2010, for an indication of spells or altered mental status. The EEGs and reports were reviewed for ictal activity, interictal epileptiform abnormalities, and nonepileptiform abnormalities. Demographic and clinical data were gathered from the electronic medical record to determine seizure predictors.

RESULTS

Of 2235 patients screened, 1048 met the inclusion criteria, of which 825 (78.7%) had an abnormal EEG finding. Seizures occurred in 78 of 1048 patients (7.4%), and interictal epileptiform discharges were noted in 194 of 1048 patients (18.5%). An intracranial mass and spells as the indication for the EEG were independently associated with the group of patients experiencing seizures in a multivariate logistic regression model (adjusted for age, sex, EEG indication, intracranial mass, stroke, and history of epilepsy). Ninety-seven percent of patients (69 of 71) experienced their first seizure within 24 hours of monitoring, and the presence of seizures was associated with a lower likelihood of being discharged (odds ratio, 0.45; 95% CI, 0.27-0.76).

CONCLUSION

Seizures occurred at a high frequency in hospitalized patients with spells and altered mental status. The EEG may be an underused investigative tool in the hospital with the potential to identify treatable causes of these common disorders.

Calculating the risk benefit equation for aggressive treatment of non-convulsive status epilepticus

OBJECTIVE

To address the question: does non-convulsive status epilepticus warrant the same aggressive treatment as convulsive status epilepticus?

METHODS

We used a decision model to evaluate the risks and benefits of treating non-convulsive status epilepticus with intravenous anesthetics and ICU-level aggressive care. We investigated how the decision to use aggressive versus non-aggressive management for non-convulsive status epilepticus impacts expected patient outcome for four etiologies: absence epilepsy, discontinued antiepileptic drugs, intraparenchymal hemorrhage, and hypoxic ischemic encephalopathy. Each etiology was defined by distinct values for five key parameters: baseline mortality rate of the inciting etiology; efficacy of non-aggressive treatment in gaining control of seizures; the relative contribution of seizures to overall mortality; the degree of excess disability expected in the case of delayed seizure control; and the mortality risk of aggressive treatment.

RESULTS

Non-aggressive treatment was favored for etiologies with low morbidity and mortality such as absence epilepsy and discontinued antiepileptic drugs. The risk of aggressive treatment was only warranted in etiologies where there was significant risk of seizure-induced neurologic damage. In the case of post-anoxic status epilepticus, expected outcomes were poor regardless of the treatment chosen. The favored strategy in each case was determined by strong interactions of all five model parameters.

CONCLUSIONS

Determination of the optimal management approach to non-convulsive status epilepticus is complex and is ultimately determined by the inciting etiology.

Emergency neurological life support: intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a subset of stroke resulting from bleeding within the brain parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an emergency neurological life support (ENLS) protocol because intervention within the first critical hour may improve outcome, and it is helpful to have a protocol to drive care quickly and efficiently.

Electrographic status epilepticus is associated with mortality and worse short-term outcome in critically ill children

OBJECTIVES

Electrographic seizures and electrographic status epilepticus are common in critically ill children. We aimed to determine whether electrographic seizures and electrographic status epilepticus are associated with higher mortality or worse short-term neurologic outcome.

DESIGN

Prospective observational study.

SETTING

PICU of a tertiary children's hospital.

PATIENTS

Non-neonatal children admitted to a PICU with acute encephalopathy underwent continuous electroencephalographic monitoring. Electroencephalographs were scored as 1) no seizures, 2) electrographic seizures, or 3) electrographic status epilepticus. Covariates included age, acute neurologic disorder category, prior neurodevelopmental status, sex, and electroencephalographic background category. Outcomes were mortality and worsening of pediatric cerebral performance category from preadmission to PICU discharge. Chi-square analysis, Fisher's exact test, and multivariable logistic regression were used to evaluate the associations between electrographic seizures or electrographic status epilepticus and mortality or short-term neurologic outcome, using odds ratios and 95% confidence intervals.

INTERVENTIONS

None.

MAIN RESULTS

Two hundred children underwent continuous electroencephalographic monitoring. Eighty-four (42%) had seizures, which were categorized as electrographic seizures in 41 (20.5%) and electrographic status epilepticus in 43 (21.5%). Thirty-six subjects (18%) died, and 88 subjects (44%) had pediatric cerebral performance category worsening. In multivariable analysis, electrographic status epilepticus was associated with an increased risk of mortality (odds ratio 5.1; 95% confidence interval 1.4, 18; p = 0.01) and pediatric cerebral performance category worsening (odds ratio 17.3; 95% confidence interval 3.7, 80; p < 0.001), whereas electrographic seizures were not associated with an increased risk of mortality (odds ratio 1.3; 95% confidence interval 0.3, 5.1; p = 0.74) or pediatric cerebral performance category worsening (odds ratio 1.2; 95% confidence interval 0.4, 3.9; p = 0.77).

CONCLUSIONS

Electrographic status epilepticus, but not electrographic seizures, is associated with mortality and worse short-term neurologic outcome in critically ill children with acute encephalopathy.

Subarachnoid Extension of Primary Intracerebral Hemorrhage is Associated With Poor Outcomes

Background and Purpose—

Extension of hemorrhage into the subarachnoid space is observed in primary intracerebral hemorrhage (ICH), yet the phenomenon has undergone limited study and is of unknown significance. The objective of this study is to evaluate the incidence, characteristics, and clinical consequences of subarachnoid hemorrhage extension (SAHE) in ICH on functional outcomes.

Methods—

Patients with primary ICH were enrolled into a prospective registry between December 2006 and June 2012. Patients were managed and serial neuroimaging was obtained per a structured protocol. Presence of any subarachnoid blood on imaging was identified as SAHE by expert reviewers blinded to outcomes. Regression models were developed to test whether the occurrence of SAHE was an independent predictor of functional outcomes as measured with the modified Rankin Scale.

Results—

Of 234 patients with ICH, 93 (39.7%) had SAHE. Interrater agreement for SAHE was excellent (kappa=0.991). SAHE was associated with lobar hemorrhage location (65% of SAHE vs 19% of non-SAHE cases; P <0.001) and larger hematoma volumes (median 23.8 vs 6.7; P <0.001). Fever (69.9% vs 51.1%; P =0.005) and seizures (8.6% vs 2.8%; P =0.07) were more common in patients with SAHE. SAHE was a predictor of death by day 14 (odds ratio, 4.45; 95% confidence interval, 1.88–10.53; P =0.001) and of higher (worse) modified Rankin Scale scores at 28 days (odds ratio, 1.76 per mRS point; 95% confidence interval, 1.01–3.05; P =0.012) after adjustment for ICH score.

Conclusions—

SAHE is associated with worse modified Rankin Scale independent of traditional ICH severity measures. Underlying mechanisms and potential treatments of SAHE require further study.

The neuro-ICU patient and electroencephalography paroxysms: if and when to treat

PURPOSE OF REVIEW

To review recent clinical data and summarize actual recommendations for the management of electrographic seizures and status epilepticus in neuro-ICU patients.

RECENT FINDINGS

Electrographic, 'nonconvulsive', seizures are frequent in neuro-ICU patients including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage and hypoxic-ischemic encephalopathy. Continuous electroencephalography monitoring is thus of great potential utility. The impact of electrographic seizures on outcome however is not entirely established and it is also unclear what type of electroencephalography paroxysms require treatment and when and how exactly to treat them. Evidence from randomized studies is lacking and will not be available in the near future. Given robust animal and human evidence showing the potential negative impact of seizures on secondary cerebral damage and outcome, treatment of seizures appears reasonable, particularly if related to status epilepticus. On the contrary, over-aggressive antiepileptic therapy entails risks. The management of seizures should therefore be guided individually, based on the underlying cause, the severity of illness and patient comorbidities.

SUMMARY

We provide a pragmatic approach for the management of electrographic seizures in neuro-ICU patients. International consensus guidelines on continuous electroencephalography monitoring and seizure therapy are needed and would represent the rationale for a future multicenter randomized trial.

Thrombin and hemin as central factors in the mechanisms of intracerebral hemorrhage-induced secondary brain injury and as potential targets for intervention

Intracerebral hemorrhage (ICH) is a subtype of stoke that may cause significant morbidity and mortality. Brain injury due to ICH initially occurs within the first few hours as a result of mass effect due to hematoma formation. However, there is increasing interest in the mechanisms of secondary brain injury as many patients continue to deteriorate clinically despite no signs of rehemorrhage or hematoma expansion. This continued insult after primary hemorrhage is believed to be mediated by the cytotoxic, excitotoxic, oxidative, and inflammatory effects of intraparenchymal blood. The main factors responsible for this injury are thrombin and erythrocyte contents such as hemoglobin. Therapies including thrombin inhibitors, N-methyl-D-aspartate antagonists, chelators to bind free iron, and antiinflammatory drugs are currently under investigation for reducing this secondary brain injury. This review will discuss the molecular mechanisms of brain injury as a result of intraparenchymal blood, potential targets for therapeutic intervention, and treatment strategies currently in development.

Intracranial hemorrhage

Intracranial hemorrhage refers to any bleeding within the intracranial vault, including the brain parenchyma and surrounding meningeal spaces. This article focuses on the acute diagnosis and management of primary nontraumatic intracerebral hemorrhage and subarachnoid hemorrhage in the emergency department.

Guidelines for the evaluation and management of status epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Continuous video EEG for patients with acute encephalopathy in a pediatric intensive care unit

OBJECTIVES

In this study, we aimed to determine the incidence of electrographic seizures among patients in a pediatric intensive care unit (PICU) presenting with acute encephalopathy. Risk factors and duration of continuous EEG monitoring needed to capture electrographic seizures were also assessed.

STUDY DESIGN

Based on a NeuroICU clinical care pathway, all patients with acute encephalopathy admitted to the PICU are monitored with continuous video electroencephalogram (cVEEG) for 48 h or until the encephalopathy improves. Ninety-four consecutive patients included on the pathway over a year were identified. Mean age was 6.7 years (range 32 days-17.9 years). Data pertaining to patient clinical information and electrographic seizures, including non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE), were extracted from a prospective database.

RESULTS

Thirty percent (28/94) had seizures captured on cVEEG including 17 patients (18%) with NCSE. Variables associated with electrographic seizures were age <24 months and clinical seizure(s) prior to EEG placement. The first seizure captured on cVEEG occurred in the first 24 h for the majority of patients (97%). Acute brain injury and electrographic seizures were associated with worse outcome.

CONCLUSIONS

Electrographic seizures are common in pediatric patients with acute encephalopathy. This study supports the practice of cVEEG monitoring for at least 24 h in pediatric patients with acute encephalopathy, particularly if they are less then 24 months of age and/or if a clinical event suspicious for seizure precedes the encephalopathy.

Seven questions about stroke and epilepsy

Seizures and stroke are both common neurologic conditions, but when they occur in close temporal proximity they produce much more concern than either does alone. The stroke specialist (and the family) fear that convulsions will worsen the stroke because of acute hypertension and airway compromise, and the epileptologist is concerned that these acute seizures are the harbingers of later epilepsy. Other less commonly recognized but important aspects of this relationship are that subclinical seizures worsen some forms of stroke, and some anticonvulsants may have more adverse effects on stroke patients than they do in other groups. In surveying the connections between these two conditions, I have attempted to address seven questions. For some questions, there are data to help provide an answer; for others, there is only opinion; and for a maddening few, newer research is making older suggestions less certain.

Absence of early epileptiform abnormalities predicts lack of seizures on continuous EEG

OBJECTIVE

To determine whether the absence of early epileptiform abnormalities predicts absence of later seizures on continuous EEG monitoring of hospitalized patients.

METHODS

We retrospectively reviewed 242 consecutive patients without a prior generalized convulsive seizure or active epilepsy who underwent continuous EEG monitoring lasting at least 18 hours for detection of nonconvulsive seizures or evaluation of unexplained altered mental status. The findings on the initial 30-minute screening EEG, subsequent continuous EEG recordings, and baseline clinical data were analyzed. We identified early EEG findings associated with absence of seizures on subsequent continuous EEG.

RESULTS

Seizures were detected in 70 (29%) patients. A total of 52 patients had their first seizure in the initial 30 minutes of continuous EEG monitoring. Of the remaining 190 patients, 63 had epileptiform discharges on their initial EEG, 24 had triphasic waves, while 103 had no epileptiform abnormalities. Seizures were later detected in 22% (n = 14) of studies with epileptiform discharges on their initial EEG, vs 3% (n = 3) of the studies without epileptiform abnormalities on initial EEG (p < 0.001). In the 3 patients without epileptiform abnormalities on initial EEG but with subsequent seizures, the first epileptiform discharge or electrographic seizure occurred within the first 4 hours of recording.

CONCLUSIONS

In patients without epileptiform abnormalities during the first 4 hours of recording, no seizures were subsequently detected. Therefore, EEG features early in the recording may indicate a low risk for seizures, and help determine whether extended monitoring is necessary.

Metabolic encephalopathies in the critical care unit

PURPOSE OF REVIEW

This article summarizes the most common etiologies and approaches to management of metabolic encephalopathy.

RECENT FINDINGS

Metabolic encephalopathy is a frequent occurrence in the intensive care unit setting. Common etiologies include hepatic failure, renal failure, sepsis, electrolyte disarray, and Wernicke encephalopathy. Current treatment paradigms typically focus on supportive care and management of the underlying etiology. Directed therapies that target neurochemical and neurotransmitter pathways that mediate encephalopathy are not currently available and represent an important area for future research. Although commonly thought of as reversible neurologic insults, delirium and encephalopathy have been associated with increased mortality, prolonged length of stay and hospital complications, and worse long-term cognitive and functional outcomes.

SUMMARY

Recognition and treatment of encephalopathy is critical to improving outcomes in critically ill patients.

Polypharmacy and the role of physical medicine and rehabilitation

Polypharmacy and inappropriate prescribing practices lead to higher rates of mortality and morbidity, particularly in vulnerable populations, such as the elderly and those with complex medical conditions. Physical medicine and physiatrists face particular challenges given the array of symptoms treated across a spectrum of conditions. This clinical review focuses on polypharmacy and the associated issue of potentially inappropriate prescribing. The article begins with a review of polypharmacy along with relevant aspects of pharmacokinetics and pharmacodynamics in the elderly. The adverse effects and potential hazards of selected medications commonly initiated and managed by rehabilitation specialists are then discussed with specific attention to pain medications, neurostimulants, antipsychotics, antidepressants, antispasmodics, sleep medications, and antiepileptics. Of particular concern is the notion that an adverse effect of one medication can mimic an indication for another and lead to a prescribing cascade and further adverse medication events. Appropriate prescribing practices mandate an accurate, current medication list, yet errors and inaccuracies often plague such lists. The evidence to support explicit (medications to avoid) and implicit (how to evaluate) criteria is presented along with the role of physicians and patients in prescribing medications. A brief discussion of "medication debridement" or de-prescribing strategies follows. In the last section, we draw on the essence of physiatry as a team-based endeavor to discuss the potential benefits of collaboration. In working to optimize medication prescribing, efforts should be made to collaborate not only with pharmacists and other medical specialties but with members of inpatient rehabilitation teams as well.

Subacute seizure incidence in thrombolysis-treated ischemic stroke patients

BACKGROUND

To assess the incidence of seizures in acute ischemic stroke patients treated with chemical (tPA) thrombolysis.

METHODS

Retrospective study including all thrombolysis patients treated in Calgary between January 1, 2001, and October 31, 2006. Descriptive statistics and age/sex-adjusted P values were calculated.

RESULTS

Of 400 eligible patients (median age 74.0 years, range: 24-77), 16 (4%) developed post-stroke seizures: 10 (62.5%) within one week (early) and 6 (37.5%) after 1 week but within the hospital stay (late). Single-vessel anterior circulation involvement (93.8% vs. 87%, P = 0.34) and hemorrhage (37.5% vs. 20%, P = 0.15) were more common in those with compared to without seizures but did not reach statistical significance. Atrial fibrillation was more common in those with (56.3%) than without (36.1%) seizures (P = 0.04). Death during admission was more likely (P = 0.03) in those who sustained seizures (37.5%) compared to those without seizures (17.6%).

CONCLUSIONS

In this cohort of tPA-treated patients, post-stroke seizures were associated with atrial fibrillation and early mortality.

Safety and efficacy of lacosamide in the intensive care unit

BACKGROUND

Seizures are common in critically ill patients and can impact morbidity and mortality. Traditional anti-epileptic drugs (AEDs) in this setting are not always effective and are associated with adverse events and drug interactions. Lacosamide (LCM) is a new AED which is available in parental form although few studies have evaluated the safety and efficacy of LCM in critically ill patients.

METHODS

Critically ill patients at Emory University Hospital who received LCM from April 1, 2009 to February 1, 2010 were retrospectively reviewed. Primary outcome measure was incidence and time to seizure cessation. Adverse effects were also recorded.

RESULTS

LCM was administered in 24 patients including 13 episodes of refractory status epilepticus (RSE) occurring in 10 patients and for treatment of isolated seizures or following resolution of RSE in an additional 14 patients. Seizure cessation was achieved in 5/13 (38%) episodes of RSE (mean 11.2 h) while there was at least a 50% decrease in seizure frequency in 7/13 (54%). 11/14 patients (76%) who received LCM for treatment of isolated seizures or prevention of seizure recurrence remained seizure free. Three patients experienced a decline in systolic blood pressure (> 20 mmHg) while one patient experienced unexplained fever and one patient had elevation of liver function tests.

CONCLUSIONS

This preliminary data suggests that LCM may be a safe and effective alternative for treatment of seizures in critically ill patients. Further prospective, randomized controlled trials are needed to confirm these findings and further explore the incidence of adverse effects.

Epileptiform activity in neurocritical care patients

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.

[EEG in intensive care unit: which indications, which material?]

There is a growing development of continuous EEG monitoring (cEEG) in the intensive care unit (ICU) management of neurological patients. Its main objective is the detection of epileptic seizures or status epilepticus because the sensitivity of standard short-duration EEG recording in the ICU is poor. The aim of monitoring is to allow rapid recognition and treatment of epileptic complications in order to decrease secondary insults to the brain and improve outcome. Several studies have demonstrated that a large proportion of patients has epileptic crisis after subarachnoid haemorrhage, stroke or brain trauma, without any clinical manifestation. The EEG feature has also demonstrated a prognosis value but its value for clinical management needs further studies. Another application of EEG in the ICU is monitoring depth of anaesthesia or barbiturate treatment. Due to artifacts contamination, this is possible only in deeply sedated of paralyzed patients. The impact or cEEG monitoring on clinical management and its indications have to be further defined.

Advances in spontaneous intracerebral haemorrhage

OBJECTIVES

  To assess the evidence and available literature on the clinical, pathogenetic, prognostic and therapeutic aspects of intracerebral haemorrhage.

METHODS

  The most important manuscripts and reviews on the subject were considered. Information was collected from Medline, Embase & National Library of Medicine over the last 40 years up to Oct 2011. The bibliographies of relevant articles were searched for additional references. The most up to date and randomised trials were given preference. Clinical guidelines including AHA/ASA, Royal college of Physicians, NICE, Scottish Intercollegiate guidelines and several others were taken into consideration.

FINDINGS

  There are numerous advances in the understanding of the pathogenesis and management, but hardly any change in the overall mortality in the last few decades. There is a poor understanding of the results of surgical trials that has resulted in a large drop in surgical intervention since 2007. INTERPRETATIONS AND IMPLICATIONS:  Advances in neuroimaging and neurophysiology have improved our understanding of the mechanisms of neuronal injury and existence of perihaematomal 'tissue at risk'. Numerous new therapeutic targets have been identified. There is a lot of misunderstanding of the results of the newer surgical trials which need to be clarified. The importance of cerebral amyloid angiopathy and microbleeds in older patients is increasingly recognised. Control of hypertension is the most important public health measure. Stroke units provide the best outcomes for the patients.

[Stroke care in the ICU: general supportive treatment. Experts' recommendations]

The French Society of Intensive Care (SRLF) requested medical experts to publish recommendations on the management of stroke in the ICU for adult and pediatric patients. The following article describes the underlying evidence used by the experts to elaborate recommendations for general supportive treatment. Such treatment is fundamental for victims of acute stroke to avoid neurological worsening. Oxygen delivery in a normoxic patient is useless. However, if saturation is below 92 %, oxygen supplementation is needed. Hyper- and hypoglycemia worsen the neurological prognosis. As no glycemic target is known, administration of insulin is required for glucose levels higher that 10 mmol/l. Body temperature above 37.5° is associated with poorer outcome. In the acute phase of stroke, high blood pressure should not be lowered except in life-threatening situations, and if so the lowering should be done cautiously. The current consensus is to lower blood pressure if the systolic pressure is above 220 mmHg or if the diastolic pressure is above 120 mmHg for ischemic stroke. For hemorrhagic stroke and after thrombolysis, treatment is needed if systolic pressure rises above 180 mmHg and if diastolic pressure is above 105 mmHg. Small doses of heparin decrease the risk of deep venous thrombosis and pulmonary embolism without increasing cerebral bleeding. There is no consensus on the treatment of epileptic crises after stroke and no dedicated treatment. Further studies are needed to define adequate blood pressure and glycemic target values in order to limit secondary worsening after an acute stroke as well as the appropriate modalities for the treatment of epilepsy.

Intracerebral hemorrhage: clinical overview and pathophysiologic concepts

Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.

Complications of intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is the most devastating type of stroke and is a leading cause of disability and mortality. By contrast with advances in ischaemic stroke treatment, few evidence-based targeted treatments exist for ICH. Management of ICH is largely supportive, with strategies aimed at the limitation of further brain injury and the prevention of associated complications, which add further detrimental effects to an already lethal disease and jeopardise clinical outcomes. Complications of ICH include haematoma expansion, perihaematomal oedema with increased intracranial pressure, intraventricular extension of haemorrhage with hydrocephalus, seizures, venous thrombotic events, hyperglycaemia, increased blood pressure, fever, and infections. In view of the restricted number of therapeutic options for patients with ICH, improved surveillance is needed for the prevention of these complications, or, when this is not possible, early detection and optimum management, which could be effective in the reduction of adverse effects early in the course of stroke and in the improvement of prognosis. Further studies are needed to enhance the evidence-based recommendations for the management of this important clinical problem.

The utility of EEG, SSEP, and other neurophysiologic tools to guide neurocritical care

Neuromonitoring is an emerging field that aims to characterize real-time neurophysiology to tailor therapy for acute injuries of the central nervous system. While cardiac telemetry has been used for decades among patients requiring critical care of all kinds, neurophysiology and neurotelemetry has only recently emerged as a routine screening tool in comatose patients. The increasing utilization of electroencephalography in comatose patients is primarily due to the recognition of the common occurrence of nonconvulsive seizures among comatose patients, the development of quantitative measures to detect regional ischemia, and the appreciation of electroencephalography phenotypes that indicate prognosis after cardiac arrest. Other neuromonitoring tools, such as somatosensory evoked potentials have a complementary role, surveying the integrity of the neuroaxis as an indicator of prognosis or illness progression in both acute brain and spinal injuries.

Therapeutic strategies in acute intracerebral hemorrhage

Intracerebral hemorrhage is a devastating disease, and no specific therapy has been proven to reduce mortality in a randomized controlled trial. However, management in a neuroscience intensive care unit does appear to improve outcomes, suggesting that many available therapies do in fact provide benefit. In the acute phase of intracerebral hemorrhage care, strategies aimed at minimizing ongoing bleeding include reversal of anticoagulation and modest blood pressure reduction. In addition, the monitoring and regulation of glucose levels, temperature, and, in selected cases, intracranial pressure are recommended by many groups. Selected patients may benefit from hematoma evacuation or external ventricular drainage. Ongoing clinical trials are examining aggressive blood pressure management, hemostatic therapy, platelet transfusion, stereotactic hematoma evacuation, and intraventricular thrombolysis. Finally, preventing recurrence of intracerebral hemorrhage is of pivotal importance, and tight blood pressure management is paramount.

MC, Lima FO, Yassuda CL, Cendes F. The impact of EEG in the diagnosis and management of patients with acute impairment of consciousness

OBJECTIVES: To assess the frequency of electroencephalogram (EEG) requests in the emergency room (ER) and intensive care unit (ICU) for patients with impairment of consciousness (IC) and its impact in the diagnosis and management. METHODS: We followed patients who underwent routine EEG from ER and ICU with IC until discharge or death. RESULTS: During the study, 1679 EEGs were performed, with 149 (8.9%) from ER and ICU. We included 65 patients and 94 EEGs to analyze. Epileptiform activity was present in 42 (44.7%). EEG results changed clinical management in 72.2% of patients. The main reason for EEG requisition was unexplained IC, representing 36.3% of all EEGs analyzed. Eleven (33%) of these had epileptiform activity. CONCLUSION: EEG is underused in the acute setting. The frequency of epileptiform activity was high in patients with unexplained IC. EEG was helpful in confirming or ruling out the suspected initial diagnosis and changing medical management in 72% of patients.