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Pyrzowski J, Kałas M, Mazurkiewicz-Bełdzińska M, Siemiński M. EEG biomarkers for the prediction of post-traumatic epilepsy - a systematic review of an emerging field. Seizure 2024; 119:71-77. [PMID: 38796954 DOI: 10.1016/j.seizure.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/24/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024] Open
Abstract
Traumatic brain injury (TBI) is often followed by post-traumatic epilepsy (PTE), a condition often difficult to treat and leading to a substantial decline in quality of life as well as increased long-term mortality. The latent period between TBI and the emergence of spontaneous recurrent seizures provides an opportunity for pharmacological intervention to prevent epileptogenesis. Biomarkers capable of predicting PTE development are urgently needed to facilitate clinical trials of putative anti-epileptogenic drugs. EEG is a widely available and flexible diagnostic modality that plays a fundamental role in epileptology. We systematically review the advances in the field of the discovery of EEG biomarkers for the prediction of PTE in humans. Despite recent progress, the field faces several challenges including short observation periods, a focus on early post-injury monitoring, difficulties in translating findings from animal models to scalp EEG, and emerging evidence indicating the importance of assessing altered background scalp EEG activity alongside epileptiform activity using quantitative EEG methods while also considering sleep abnormalities in future studies.
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Affiliation(s)
- Jan Pyrzowski
- Department of Emergency Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| | - Maria Kałas
- Department of Emergency Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Mariusz Siemiński
- Department of Emergency Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Fung FW, Parikh DS, Donnelly M, Jacobwitz M, Topjian AA, Xiao R, Abend NS. EEG Monitoring in Critically Ill Children: Establishing High-Yield Subgroups. J Clin Neurophysiol 2024; 41:305-311. [PMID: 36893385 PMCID: PMC10492893 DOI: 10.1097/wnp.0000000000000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
PURPOSE Continuous EEG monitoring (CEEG) is increasingly used to identify electrographic seizures (ES) in critically ill children, but it is resource intense. We aimed to assess how patient stratification by known ES risk factors would impact CEEG utilization. METHODS This was a prospective observational study of critically ill children with encephalopathy who underwent CEEG. We calculated the average CEEG duration required to identify a patient with ES for the full cohort and subgroups stratified by known ES risk factors. RESULTS ES occurred in 345 of 1,399 patients (25%). For the full cohort, an average of 90 hours of CEEG would be required to identify 90% of patients with ES. If subgroups of patients were stratified by age, clinically evident seizures before CEEG initiation, and early EEG risk factors, then 20 to 1,046 hours of CEEG would be required to identify a patient with ES. Patients with clinically evident seizures before CEEG initiation and EEG risk factors present in the initial hour of CEEG required only 20 (<1 year) or 22 (≥1 year) hours of CEEG to identify a patient with ES. Conversely, patients with no clinically evident seizures before CEEG initiation and no EEG risk factors in the initial hour of CEEG required 405 (<1 year) or 1,046 (≥1 year) hours of CEEG to identify a patient with ES. Patients with clinically evident seizures before CEEG initiation or EEG risk factors in the initial hour of CEEG required 29 to 120 hours of CEEG to identify a patient with ES. CONCLUSIONS Stratifying patients by clinical and EEG risk factors could identify high- and low-yield subgroups for CEEG by considering ES incidence, the duration of CEEG required to identify ES, and subgroup size. This approach may be critical for optimizing CEEG resource allocation.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Darshana S Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Marin Jacobwitz
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphi||a, Pennsylvania, U.S.A
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.; and
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.; and
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A
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Fung FW, Parikh DS, Walsh K, Fitzgerald MP, Massey SL, Topjian AA, Abend NS. Late-Onset Findings During Extended EEG Monitoring Are Rare in Critically Ill Children. J Clin Neurophysiol 2024:00004691-990000000-00131. [PMID: 38687298 DOI: 10.1097/wnp.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
PURPOSE Electrographic seizures (ES) are common in critically ill children undergoing continuous EEG (CEEG) monitoring, and previous studies have aimed to target limited CEEG resources to children at highest risk of ES. However, previous studies have relied on observational data in which the duration of CEEG was clinically determined. Thus, the incidence of late occurring ES is unknown. The authors aimed to assess the incidence of ES for 24 hours after discontinuation of clinically indicated CEEG. METHODS This was a single-center prospective study of nonconsecutive children with acute encephalopathy in the pediatric intensive care unit who underwent 24 hours of extended research EEG after the end of clinical CEEG. The authors assessed whether there were new findings that affected clinical management during the extended research EEG, including new-onset ES. RESULTS Sixty-three subjects underwent extended research EEG. The median duration of the extended research EEG was 24.3 hours (interquartile range 24.0-25.3). Three subjects (5%) had an EEG change during the extended research EEG that resulted in a change in clinical management, including an increase in ES frequency, differential diagnosis of an event, and new interictal epileptiform discharges. No subjects had new-onset ES during the extended research EEG. CONCLUSIONS No subjects experienced new-onset ES during the 24-hour extended research EEG period. This finding supports observational data that patients with late-onset ES are rare and suggests that ES prediction models derived from observational data are likely not substantially underrepresenting the incidence of late-onset ES after discontinuation of clinically indicated CEEG.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Darshana S Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathleen Walsh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark P Fitzgerald
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Shavonne L Massey
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; and
- Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Coleman K, Fung FW, Topjian A, Abend NS, Xiao R. Optimizing EEG monitoring in critically ill children at risk for electroencephalographic seizures. Seizure 2024; 117:244-252. [PMID: 38522169 DOI: 10.1016/j.seizure.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/06/2024] [Accepted: 03/19/2024] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE Strategies are needed to optimally deploy continuous EEG monitoring (CEEG) for electroencephalographic seizure (ES) identification and management due to resource limitations. We aimed to construct an efficient multi-stage prediction model guiding CEEG utilization to identify ES in critically ill children using clinical and EEG covariates. METHODS The largest prospective single-center cohort of 1399 consecutive children undergoing CEEG was analyzed. A four-stage model was developed and trained to predict whether a subject required additional CEEG at the conclusion of each stage given their risk of ES. Logistic regression, elastic net, random forest, and CatBoost served as candidate methods for each stage and were evaluated using cross validation. An optimal multi-stage model consisting of the top-performing stage-specific models was constructed. RESULTS When evaluated on a test set, the optimal multi-stage model achieved a cumulative specificity of 0.197 and cumulative F1 score of 0.326 while maintaining a high minimum cumulative sensitivity of 0.938. Overall, 11 % of test subjects with ES were removed from the model due to a predicted low risk of ES (falsely negative subjects). CEEG utilization would be reduced by 32 % and 47 % compared to performing 24 and 48 h of CEEG in all test subjects, respectively. We developed a web application called EEGLE (EEG Length Estimator) that enables straightforward implementation of the model. CONCLUSIONS Application of the optimal multi-stage ES prediction model could either reduce CEEG utilization for patients at lower risk of ES or promote CEEG resource reallocation to patients at higher risk for ES.
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Affiliation(s)
- Kyle Coleman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, United States
| | - France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, United States; Department of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, United States
| | - Alexis Topjian
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, United States
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, United States; Department of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, United States; Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, United States
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, United States.
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Kazis D, Chatzikonstantinou S, Ciobica A, Kamal FZ, Burlui V, Calin G, Mavroudis I. Epidemiology, Risk Factors, and Biomarkers of Post-Traumatic Epilepsy: A Comprehensive Overview. Biomedicines 2024; 12:410. [PMID: 38398011 PMCID: PMC10886732 DOI: 10.3390/biomedicines12020410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
This paper presents an in-depth exploration of Post-Traumatic Epilepsy (PTE), a complex neurological disorder following traumatic brain injury (TBI), characterized by recurrent, unprovoked seizures. With TBI being a global health concern, understanding PTE is crucial for effective diagnosis, management, and prognosis. This study aims to provide a comprehensive overview of the epidemiology, risk factors, and emerging biomarkers of PTE, thereby informing clinical practice and guiding future research. The epidemiological aspect of the study reveals PTE as a significant contributor to acquired epilepsies, with varying incidence influenced by injury severity, age, and intracranial pathologies. The paper delves into the multifactorial nature of PTE risk factors, encompassing clinical, demographic, and genetic elements. Key insights include the association of injury severity, intracranial hemorrhages, and early seizures with increased PTE risk, and the roles of age, gender, and genetic predispositions. Advancements in neuroimaging, electroencephalography, and molecular biology are presented, highlighting their roles in identifying potential PTE biomarkers. These biomarkers, ranging from radiological signs to electroencephalography EEG patterns and molecular indicators, hold promise for enhancing PTE pathogenesis understanding, early diagnosis, and therapeutic guidance. The paper also discusses the critical roles of astrocytes and microglia in PTE, emphasizing the significance of neuroinflammation in PTE development. The insights from this review suggest potential therapeutic targets in neuroinflammation pathways. In conclusion, this paper synthesizes current knowledge in the field, emphasizing the need for continued research and a multidisciplinary approach to effectively manage PTE. Future research directions include longitudinal studies for a better understanding of TBI and PTE outcomes, and the development of targeted interventions based on individualized risk profiles. This research contributes significantly to the broader understanding of epilepsy and TBI.
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Affiliation(s)
- Dimitrios Kazis
- Third Department of Neurology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (D.K.)
| | - Symela Chatzikonstantinou
- Third Department of Neurology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (D.K.)
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University of Iasi, 20th Carol I Avenue, 700506 Iasi, Romania;
- Center of Biomedical Research, Romanian Academy, Iasi Branch, Teodor Codrescu 2, 700481 Iasi, Romania
- Academy of Romanian Scientists, 3 Ilfov, 050044 Bucharest, Romania
| | - Fatima Zahra Kamal
- Higher Institute of Nursing Professions and Health Technical (ISPITS), Marrakech 40000, Morocco
- Laboratory of Physical Chemistry of Processes and Materials, Faculty of Sciences and Techniques, Hassan First University, Settat 26000, Morocco
| | - Vasile Burlui
- Department of Biomaterials, Faculty of Dental Medicine, Apollonia University, 700511 Iasi, Romania;
| | - Gabriela Calin
- Department of Biomaterials, Faculty of Dental Medicine, Apollonia University, 700511 Iasi, Romania;
| | - Ioannis Mavroudis
- Department of Neuroscience, Leeds Teaching Hospitals, Leeds LS2 9JT, UK
- Faculty of Medicine, Leeds University, Leeds LS2 9JT, UK
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Agrawal S, Abecasis F, Jalloh I. Neuromonitoring in Children with Traumatic Brain Injury. Neurocrit Care 2024; 40:147-158. [PMID: 37386341 PMCID: PMC10861621 DOI: 10.1007/s12028-023-01779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
Traumatic brain injury remains a major cause of mortality and morbidity in children across the world. Current management based on international guidelines focuses on a fixed therapeutic target of less than 20 mm Hg for managing intracranial pressure and 40-50 mm Hg for cerebral perfusion pressure across the pediatric age group. To improve outcome from this complex disease, it is essential to understand the pathophysiological mechanisms responsible for disease evolution by using different monitoring tools. In this narrative review, we discuss the neuromonitoring tools available for use to help guide management of severe traumatic brain injury in children and some of the techniques that can in future help with individualizing treatment targets based on advanced cerebral physiology monitoring.
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Affiliation(s)
- Shruti Agrawal
- Department of Paediatric Intensive Care, Cambridge University Hospitals National Health Service Foundation Trust, Level 3, Box 7, Addenbrookes Hospital Hills Road, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
| | - Francisco Abecasis
- Paediatric Intensive Care Unit, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ibrahim Jalloh
- University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
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Fung FW, Parikh DS, Donnelly M, Xiao R, Topjian AA, Abend NS. Electrographic Seizure Characteristics and Electrographic Status Epilepticus Prediction. J Clin Neurophysiol 2024:00004691-990000000-00117. [PMID: 38194638 DOI: 10.1097/wnp.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
PURPOSE We aimed to characterize electrographic seizures (ES) and electrographic status epilepticus (ESE) and determine whether a model predicting ESE exclusively could effectively guide continuous EEG monitoring (CEEG) utilization in critically ill children. METHODS This was a prospective observational study of consecutive critically ill children with encephalopathy who underwent CEEG. We used descriptive statistics to characterize ES and ESE, and we developed a model for ESE prediction. RESULTS ES occurred in 25% of 1,399 subjects. Among subjects with ES, 23% had ESE, including 37% with continuous seizures lasting >30 minutes and 63% with recurrent seizures totaling 30 minutes within a 1-hour epoch. The median onset of ES and ESE occurred 1.8 and 0.18 hours after CEEG initiation, respectively. The optimal model for ESE prediction yielded an area under the receiver operating characteristic curves of 0.81. A cutoff selected to emphasize sensitivity (91%) yielded specificity of 56%. Given the 6% ESE incidence, positive predictive value was 11% and negative predictive value was 99%. If the model were applied to our cohort, then 53% of patients would not undergo CEEG and 8% of patients experiencing ESE would not be identified. CONCLUSIONS ESE was common, but most patients with ESE had recurrent brief seizures rather than long individual seizures. A model predicting ESE might only slightly improve CEEG utilization over models aiming to identify patients at risk for ES but would fail to identify some patients with ESE. Models identifying ES might be more advantageous for preventing ES from evolving into ESE.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, U.S.A
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
| | - Darshana S Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, U.S.A
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, U.S.A
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, U.S.A.; and
- Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, U.S.A
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, U.S.A
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
- Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, U.S.A
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Laaksonen J, Ponkilainen V, Kuitunen I, Möttönen J, Mattila VM. Association between pediatric traumatic brain injury and epilepsy at later ages in Finland: A nationwide register-based cohort study. Epilepsia 2023; 64:3257-3265. [PMID: 37867469 DOI: 10.1111/epi.17805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This study was undertaken to examine how pediatric traumatic brain injury (pTBI) correlates with incidence of epilepsy at later ages in Finland. METHODS This nationwide retrospective register-based cohort study extended from 1998 to 2018. The study group consisted of 71 969 pediatric (<18 years old) patients hospitalized with TBI and a control group consisting of 64 856 pediatric patients with distal extremity fracture. Epilepsy diagnoses were gathered from the Finnish Social Insurance Institution. Kaplan-Meier and multivariable Cox regression models were conducted to analyze the probability of epilepsy with 95% confidence intervals (CIs). RESULTS Cumulative incidence rates (CIRs) for the first 2 years were .5% in the pTBI group and .1% in the control group. The corresponding rates after 15 years of follow-up were 1.5% in the pTBI group and .7% in the control group. Due to proportional hazard violations, the study population was split to the first 2 years and in subgroup analysis 4 years. During the first 2 years of surveillance, the hazard ratio (HR) for the pTBI group was 4.38 (95% CI = 3.39-5.66). However, between years 2 and 20, the HR for the pTBI group was 2.02 (95% CI = 1.71-2.38). A total of 337 patients (.47%) underwent neurosurgery, and 36 (10.7%) patients subsequently developed epilepsy. The CIR for the first year after TBI was 4.5% (95% CI = 2.3-6.7) in operatively managed patients and .3% (95% CI = .3-.4) in nonoperatively managed patients. Corresponding figures after 15 years were 12.0% (95% CI = 8.2-15.8) and 1.5% (95% CI = 1.4-1.6). During the first 4 years of surveillance, the HR for the operative pTBI group was 14.37 (95% CI = 9.29-20.80) and 3.67 (95% CI = 1.63-8.22) between years 4 and 20. SIGNIFICANCE pTBI exposes patients to a higher risk for posttraumatic epilepsy for many years after initial trauma. Children who undergo operative management for TBI have a high risk for epilepsy, and this risk was highest during the first 4 years after injury.
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Affiliation(s)
- Juho Laaksonen
- School of Medicine, University of Tampere, Tampere, Finland
| | - Ville Ponkilainen
- Department of Surgery, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Julius Möttönen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- School of Medicine, University of Tampere, Tampere, Finland
- Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
- Coxa Hospital for Joint Replacement, Tampere, Finland
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Cavusoglu D, Olgac Dundar N, Kamit F, Anil AB, Arican P, Zengin N, Gencpinar P. Evaluation of Nonconvulsive Status Epilepticus and Nonconvulsive Seizures in a Pediatric Intensive Care Unit. Clin Pediatr (Phila) 2023; 62:879-884. [PMID: 36691331 DOI: 10.1177/00099228221150687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We aimed to identify nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE) in a pediatric intensive care unit (PICU). A prospective cohort study on 35 patients who underwent continuous electroencephalographic monitoring in the PICU was done. The patients were evaluated to collect data of their demographics, clinical diagnoses, clinical seizures by electroencephalography, and neuroimaging findings. One case with NCSE and 4 cases with NCS were diagnosed among the 35 patients. The etiology of the patient with NCSE showed antiepileptic drug (AED) withdrawal. The etiology of the patients with NCS included electrical injury, head trauma, subarachnoid hemorrhage, and pneumonia. The findings suggest that younger age, epilepsy, acute structural brain abnormalities, abrupt cessation of AED, and clinically overt seizures before NCSE/NCS are associated with significant risk for NCS/NCSE. In addition, the electrical injury may also be considered as a risk factor for electrographic seizure though such a case has not yet been reported.
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Affiliation(s)
- Dilek Cavusoglu
- Department of Pediatric Neurology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyon, Turkey
| | - Nihal Olgac Dundar
- Department of Pediatric Neurology, Faculty of Medicine, Tepecik Training and Investigation Hospital, İzmir Katip Celebi University, Izmir, Turkey
| | - Fulya Kamit
- Department of Pediatric Intensive Care, İstanbul Gaziosmanpasa Hospital, Yeni Yuzyil University, Istanbul, Turkey
| | - Ayse Berna Anil
- Department of Pediatric Intensive Care, Faculty of Medicine, İzmir Katip Celebi University, Izmir, Turkey
| | - Pinar Arican
- Department of Pediatric Neurology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Neslihan Zengin
- Department of Pediatric Intensive Care, Izmir Buca Obstetrics and Pediatrics Hospital, Izmir, Turkey
| | - Pinar Gencpinar
- Department of Pediatric Neurology, Faculty of Medicine, Tepecik Training and Investigation Hospital, İzmir Katip Celebi University, Izmir, Turkey
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Guerriero RM, Morrissey MJ, Loe M, Reznikov J, Binkley MM, Ganniger A, Griffith JL, Khanmohammadi S, Rudock R, Guilliams KP, Ching S, Tomko SR. Macroperiodic Oscillations Are Associated With Seizures Following Acquired Brain Injury in Young Children. J Clin Neurophysiol 2022; 39:602-609. [PMID: 33587388 PMCID: PMC8674933 DOI: 10.1097/wnp.0000000000000828] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Seizures occur in 10% to 40% of critically ill children. We describe a phenomenon seen on color density spectral array but not raw EEG associated with seizures and acquired brain injury in pediatric patients. METHODS We reviewed EEGs of 541 children admitted to an intensive care unit between October 2015 and August 2018. We identified 38 children (7%) with a periodic pattern on color density spectral array that oscillates every 2 to 5 minutes and was not apparent on the raw EEG tracing, termed macroperiodic oscillations (MOs). Internal validity measures and interrater agreement were assessed. We compared demographic and clinical data between those with and without MOs. RESULTS Interrater reliability yielded a strong agreement for MOs identification (kappa: 0.778 [0.542-1.000]; P < 0.0001). There was a 76% overlap in the start and stop times of MOs among reviewers. All patients with MOs had seizures as opposed to 22.5% of the general intensive care unit monitoring population ( P < 0.0001). Macroperiodic oscillations occurred before or in the midst of recurrent seizures. Patients with MOs were younger (median of 8 vs. 208 days; P < 0.001), with indications for EEG monitoring more likely to be clinical seizures (42 vs. 16%; P < 0.001) or traumatic brain injury (16 vs. 5%, P < 0.01) and had fewer premorbid neurologic conditions (10.5 vs. 33%; P < 0.01). CONCLUSIONS Macroperiodic oscillations are a slow periodic pattern occurring over a longer time scale than periodic discharges in pediatric intensive care unit patients. This pattern is associated with seizures in young patients with acquired brain injuries.
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Affiliation(s)
- Réjean M. Guerriero
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Michael J. Morrissey
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Maren Loe
- Medical Scientist Training Program, Washington University School of Medicine, Washington University School of Medicine, St. Louis, Missouri, U.S.A
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Joseph Reznikov
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Michael M. Binkley
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Alex Ganniger
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Jennifer L. Griffith
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Sina Khanmohammadi
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Robert Rudock
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Kristin P. Guilliams
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - ShiNung Ching
- Department of Electrical and Systems Engineering, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Stuart R. Tomko
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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12
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Cuenca CM, Borgman MA, Dengler BA, Schauer SG. Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq. Injury 2022; 53:3297-3300. [PMID: 35831207 DOI: 10.1016/j.injury.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. METHODS This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. RESULTS Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). CONCLUSIONS Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | | | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda Maryland, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA; Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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13
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Raikot SR, Polites SF. Current management of pediatric traumatic brain injury. Semin Pediatr Surg 2022; 31:151215. [PMID: 36399949 DOI: 10.1016/j.sempedsurg.2022.151215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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The Role of Electroencephalography in the Prognostication of Clinical Outcomes in Critically Ill Children: A Review. CHILDREN 2022; 9:children9091368. [PMID: 36138677 PMCID: PMC9497701 DOI: 10.3390/children9091368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022]
Abstract
Electroencephalography (EEG) is a neurologic monitoring modality that allows for the identification of seizures and the understanding of cerebral function. Not only can EEG data provide real-time information about a patient’s clinical status, but providers are increasingly using these results to understand short and long-term prognosis in critical illnesses. Adult studies have explored these associations for many years, and now the focus has turned to applying these concepts to the pediatric literature. The aim of this review is to characterize how EEG can be utilized clinically in pediatric intensive care settings and to highlight the current data available to understand EEG features in association with functional outcomes in children after critical illness. In the evaluation of seizures and seizure burden in children, there is abundant data to suggest that the presence of status epilepticus during illness is associated with poorer outcomes and a higher risk of mortality. There is also emerging evidence indicating that poorly organized EEG backgrounds, lack of normal sleep features and lack of electrographic reactivity to clinical exams portend worse outcomes in this population. Prognostication in pediatric critical illness must be informed by the comprehensive evaluation of a patient’s clinical status but the utilization of EEG may help contribute to this assessment in a meaningful way.
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15
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Rubinos C, Waters B, Hirsch LJ. Predicting and Treating Post-traumatic Epilepsy. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Current and Potential Pharmacologic Therapies for Traumatic Brain Injury. Pharmaceuticals (Basel) 2022; 15:ph15070838. [PMID: 35890136 PMCID: PMC9323622 DOI: 10.3390/ph15070838] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
The present article reviewed the pharmacologic therapies of traumatic brain injury (TBI), including current and potential treatments. Pharmacologic therapies are an essential part of TBI care, and several agents have well-established effects in TBI care. In the acute phase, tranexamic acid, antiepileptics, hyperosmolar agents, and anesthetics are the mainstay of pharmacotherapy, which have proven efficacies. In the post-acute phase, SSRIs, SNRIs, antipsychotics, zolpidem and amantadine, as well as other drugs, have been used to manage neuropsychological problems, while muscle relaxants and botulinum toxin have been used to manage spasticity. In addition, increasing numbers of pre-clinical and clinical studies of pharmaceutical agents, including potential neuroprotective nutrients and natural therapies, are being carried out. In the present article, we classify the treatments into established and potential agents based on the level of clinical evidence and standard of practice. It is expected that many of the potential medicines under investigation will eventually be accepted as standard practice in the care of TBI patients.
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Abstract
Brain injury in children is a major public health problem, causing substantial morbidity and mortality. Cause of pediatric brain injury varies widely and can be from a primary neurologic cause or as a sequela of multisystem illness. This review discusses the emerging field of pediatric neurocritical care (PNCC), including current techniques of imaging, treatment, and monitoring. Future directions of PNCC include further expansion of evidence-based practice guidelines and establishment of multidisciplinary PNCC services within institutions.
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Affiliation(s)
- Ajit A Sarnaik
- Central Michigan University College of Medicine, Carls Building, Pediatric Critical Care, Children's Hospital of Michigan, 3901 Beaubien Avenue, Detroit, MI 48201, USA.
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18
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Park YS. Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants. J Korean Neurosurg Soc 2022; 65:385-396. [PMID: 35468708 PMCID: PMC9082116 DOI: 10.3340/jkns.2021.0289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.
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Affiliation(s)
- Young Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University, Kashihara, Japan
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19
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He C, Chen C, Yang Y, Hu L, Jin B, Ming W, Wang Z, Ding Y, Ding M, Wang S, Wang S. Clinical Characteristics and Prognostic Significance of Subclinical Seizures in Focal Epilepsy: A Retrospective Study. Neurol Ther 2022; 11:763-779. [PMID: 35378679 PMCID: PMC9095772 DOI: 10.1007/s40120-022-00342-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/09/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The aim was to evaluate the clinical characteristics and prognostic significance of subclinical seizures (SCSs) on scalp video-electroencephalogram (VEEG) monitoring with or without intracranial electroencephalogram (IEEG) monitoring in patients who had epilepsy surgery. METHODS We reviewed 286 epileptic patients who underwent subsequent epilepsy surgery during scalp-VEEG evaluation with or without IEEG monitoring between 2013 and 2020, with a minimum follow-up of 1 year. The prevalence and clinical characteristics of SCSs, as well as their prognostic significance, were analyzed. RESULTS A total of 286 patients were enrolled for analysis, and 80 patients had IEEG implanted. SCSs were recorded in 9.79% of the patients based on VEEG and 50% based on IEEG. In the VEEG group (n = 286), younger seizure onset (P = 0.004) was associated with the presence of s-SCSs (SCSs detected on scalp VEEG). In the IEEG group (n = 80), temporal lobe epilepsy (P = 0.015) was associated with the presence of i-SCSs (SCSs detected on IEEG). Of 286 patients, 208 (72.73%) were seizure-free in the VEEG group, and 56 0f 80 patients (70%) were seizure-free in the IEEG group through the last follow-up. In the VEEG group, the presence of s-SCSs did not affect seizure outcome; predictors of seizure recurrence were longer epilepsy duration (P = 0.003, OR 1.003, 95% CI 1.001-1.005), history of focal to bilateral tonic-clonic seizure (P = 0.027, OR 1.665, 95% CI 1.060-2.613), nonspecific pathology (P = 0.018, OR 2.184, 95% CI 1.145-4.163), and incomplete resection (P = 0.004, OR 2.705, 95% CI 1.372-5.332). In the IEEG group, i-SCSs were significantly associated with seizure outcome (P = 0.028, OR 0.371, 95% CI 0.153-0.898). CONCLUSION The rate of SCSs captured on IEEG monitoring was higher than that on VEEG monitoring during presurgical evaluation. SCSs detected on VEEG monitoring were associated with younger seizure onset. SCSs detected on IEEG monitoring were associated with temporal lobe epilepsy and also predicted surgical outcomes in focal epilepsy.
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Affiliation(s)
- Chenmin He
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Cong Chen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yuyu Yang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Lingli Hu
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Bo Jin
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Wenjie Ming
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Zhongjin Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yao Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Meiping Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Shuang Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China.
| | - Shan Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China.
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20
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Ji J, Qian SY, Liu J, Gao HM. Occurrence of early epilepsy in children with traumatic brain injury: a retrospective study. World J Pediatr 2022; 18:214-221. [PMID: 35150398 DOI: 10.1007/s12519-021-00502-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early post-traumatic seizures (EPTS) refer to epileptic seizures occurring within one week after brain injury. This study aimed to define the risk factors of EPTS and the protective factors that could prevent its occurrence. METHODS This is a single-center retrospective study in the PICU, Beijing Children's Hospital. Patients diagnosed with traumatic brain injury (TBI), admitted with and without EPTS between January 2016 and December 2020 were included in the study. RESULTS We included 108 patients diagnosed with TBI. The overall EPTS incidence was 33.98% (35/108). The correlation between EPTS and depressed fractures is positive (P = 0.023). Positive correlations between EPTS and intracranial hemorrhage and subarachnoid hemorrhage had been established (P = 0.011and P = 0.004, respectively). The detection rates of EPTS in the electroencephalogram (EEG) monitoring was 80.00%. There was a significant difference in the EEG monitoring rate between the two groups (P = 0.041). Forty-one (37.86%, 41/108) post-neurosurgical patients were treated with prophylactic antiepileptic drugs (AEDs), and eight (19.51%, 8/41) still had seizures. No statistical significance was noted between the two groups in terms of prophylactic AEDs use (P = 0.519). Logistic regression analysis revealed that open craniocerebral injury and fever on admission were risk factors for EPTS, whereas, surgical intervention and use of hypertonic saline were associated with not developing EPTS. CONCLUSIONS Breakthrough EPTS occurred after severe TBI in 33.98% of pediatric cases in our cohort. This is a higher seizure incidence than that reported previously. Patients with fever on admission and open craniocerebral injuries are more likely to develop EPTS.
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Affiliation(s)
- Jian Ji
- Pediatric Intensive Care Unit, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 45 Nanlishi Road, Beijing, 100045, China
| | - Su-Yun Qian
- Pediatric Intensive Care Unit, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 45 Nanlishi Road, Beijing, 100045, China.
| | - Jun Liu
- Pediatric Intensive Care Unit, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 45 Nanlishi Road, Beijing, 100045, China
| | - Heng-Miao Gao
- Pediatric Intensive Care Unit, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 45 Nanlishi Road, Beijing, 100045, China
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21
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Nickerson TE, Villo L, Eisner M, Lovett ME, Chung MG, O'Brien NF, Sribnick EA, Ostendorf AP. Associations between Electroencephalographic Variables, Early Post-Traumatic Seizure Risk, and Outcomes following Pediatric Severe Traumatic Brain Injury. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1743500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractEarly post-traumatic seizures (PTS) are associated with worse outcomes in children with traumatic brain injury (TBI). Our aim was to identify the association between continuous electroencephalogram (cEEG) characteristics and early PTS risk following pediatric severe TBI. We also evaluated the relationship between cEEG background features and outcomes. A single-center retrospective cohort study was performed on children between 0 and 18 years of age admitted to the pediatric intensive care unit from 2016 to 2019 with severe TBI and cEEG monitoring within 7 days of injury. Raw cEEG tracings were reviewed by an epileptologist in accordance with American Clinical Neurophysiology Society (ACNS) Critical Care EEG terminology. Univariate comparisons were made between children with and without early PTS, as well as between those with and without varying cEEG background features. Eighteen children (31%) of the 59 included had early PTS. Interictal abnormalities, inclusive of sporadic spikes and sharp waves, rhythmic delta activity, or lateralized periodic discharges (LPDs) were more common among children with seizures (100 vs. 22%; p < 0.01). LPDs were also more common in the seizure group (44 vs. 2%; p < 0.01). Background discontinuity was associated with worse Glasgow Outcome Scale—Extended Pediatric Version (GOS-E Peds) scores at discharge and 3-, 6-, and 12-month post-discharge (p < 0.01). Lack of reactivity was also associated with worse GOS-E Peds scores at 3-, 6-, and 12-month post-discharge (p < 0.01). Interictal abnormalities and LPDs were each associated with early PTS following pediatric severe TBI. Larger studies should evaluate if high-risk patients would benefit from prolonged cEEG monitoring and/or more aggressive anti-seizure prophylaxis. Discontinuity and lack of variability were associated with worse outcomes. Future studies should attempt to clarify their role as potential early markers of prognosis.
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Affiliation(s)
- Taylor E. Nickerson
- Division of Critical Care Medicine, Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, United States
| | - Lauren Villo
- Division of Critical Care Medicine, Department of Pediatrics, Atrium Health Navicent, Mercer University, Macon, Georgia, United States
| | - Mariah Eisner
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, United States
| | - Marlina E. Lovett
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Melissa G. Chung
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
- Division of Neurology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Eric A. Sribnick
- Division of Neurological Surgery, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Adam P. Ostendorf
- Division of Neurology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
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22
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Chong SL, Qian S, Yao SHW, Allen JC, Dang H, Chan LCN, Ming M, Gan CS, Ong JSM, Kurosawa H, Lee JH. Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis. J Neurosurg Pediatr 2022; 29:225-231. [PMID: 34715667 DOI: 10.3171/2021.8.peds21281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia. METHODS A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale. RESULTS Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8-8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78-0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05-4.10; p = 0.036). CONCLUSIONS EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.
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Affiliation(s)
- Shu-Ling Chong
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
| | - Suyun Qian
- 3Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sarah Hui Wen Yao
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | | | - Hongxing Dang
- 5Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Lawrence C N Chan
- 6Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Meixiu Ming
- 7Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Chin Seng Gan
- 8Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Jacqueline S M Ong
- 9Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- 10Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- 11Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; and
| | - Jan Hau Lee
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
- 12Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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23
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Non-accidental Trauma in Infants: a Review of Evidence-Based Strategies for Diagnosis, Management, and Prevention. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-021-00221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide a resource for providers that may be involved in the diagnosis and management of infant non-accidental trauma (NAT).
Recent Findings
Infants are more likely to both suffer from physical abuse and die from their subsequent injuries. There are missed opportunities among providers for recognizing sentinel injuries. Minority children are overrepresented in the reporting of child maltreatment, and there is systemic bias in the evaluation and treatment of minority victims of child abuse.
Summary
Unfortunately, no single, primary preventative intervention has been conclusively shown to reduce the incidence of child maltreatment. Standardized algorithms for NAT screening have been shown to increase the bias-free utilization of NAT evaluations. Every healthcare provider that interacts with children has a responsibility to recognize warning signs of NAT, be able to initiate the evaluation for suspected NAT, and understand their role as a mandatory reporter.
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24
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Surtees TL, Kumar I, Garton HJL, Rivas-Rodriguez F, Parmar H, McCaffery H, Riebe-Rodgers J, Shellhaas RA. Levetiracetam Prophylaxis for Children Admitted With Traumatic Brain Injury. Pediatr Neurol 2022; 126:114-119. [PMID: 34839268 DOI: 10.1016/j.pediatrneurol.2021.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed. METHODS This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted. RESULTS Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin. CONCLUSIONS Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.
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Affiliation(s)
- Taryn-Leigh Surtees
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
| | - Ishani Kumar
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | | | - Hemant Parmar
- Radiology, University of Michigan, Ann Arbor, Michigan
| | - Harlan McCaffery
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Renée A Shellhaas
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
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Snooks KC, Yan K, Farias-Moeller R, Fink EL, Hanson SJ. Continuous Electroencephalogram and Antiseizure Medication Use in an International Pediatric Traumatic Brain Injury Population. Neurocrit Care 2021; 36:573-583. [PMID: 34553297 DOI: 10.1007/s12028-021-01337-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/17/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrographic seizures are frequent and associated with worse outcomes following traumatic brain injury (TBI). Despite this, the use of continuous electroencephalogram (cEEG) remains low. Our study describes cEEG usage and treatment dosing antiseizure medications (ASMs) in an international pediatric TBI population, hypothesizing that children monitored with cEEG have an increased rate of treatment ASMs because of electrographic seizure detection, compared with children who are not monitored with cEEG. METHODS This subanalysis of the TBI cohort of the international PANGEA study included children, 7 days to 17 years of age, with acute neurological insults admitted to pediatric intensive care units. We analyzed demographics, injury severity, and therapies including prophylactic or treatment ASMs. We evaluated the relationships between cEEG use, seizure frequency, and receipt of treatment ASMs. [Formula: see text] or Fisher's exact test was used to analyze categorical variables, and the Kruskal-Wallis or Mann-Whitney U-test was used for continuous variables. Multivariable analysis for treatment ASM use was performed using logistic regression. RESULTS One hundred-twenty-three of 174 patients with TBI were included. Twenty-seven patients (21.9%) underwent cEEG at any point during pediatric intensive care unit admission. Preexisting seizure disorder (18.2% vs. 2.3%, p = 0.014) and neuromuscular blockade use (52.4% vs. 24.1%, p = 0.011) were more frequently observed in the group monitored on cEEG when compared with those that were not. Presenting median Glasgow Coma Scale score was worse in the cEEG group (7 vs. 9, p = 0.044). There was no significant difference in age, use of intracranial pressure monitoring, or hyperosmolar therapy between the cEEG monitored and nonmonitored groups. Patients who were monitored on cEEG were more likely to receive a treatment dose ASM than those without cEEG monitoring (66.7% vs. 28.1%, p = 0.0002). When compared with those without treatment ASM, the treatment ASM group had more electrographic seizures on their first electroencephalogram following injury (51.6% vs. 4%, p = 0.0001) and more clinical seizures (55.8% vs. 0%, p < 0.0001). CONCLUSIONS Children monitored with cEEG after TBI have an increased prescription of treatment ASMs and clinical and electrographic seizures. The increased rate of treatment ASMs in the cEEG group may indicate increased recognition of electrographic seizures.
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Affiliation(s)
- Kellie C Snooks
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Ke Yan
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | | | - Ericka L Fink
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sheila J Hanson
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
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Pototskiy E, Dellinger JR, Bumgarner S, Patel J, Sherrerd-Smith W, Musto AE. Brain injuries can set up an epileptogenic neuronal network. Neurosci Biobehav Rev 2021; 129:351-366. [PMID: 34384843 DOI: 10.1016/j.neubiorev.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
Development of epilepsy or epileptogenesis promotes recurrent seizures. As of today, there are no effective prophylactic therapies to prevent the onset of epilepsy. Contributing to this deficiency of preventive therapy is the lack of clarity in fundamental neurobiological mechanisms underlying epileptogenesis and lack of reliable biomarkers to identify patients at risk for developing epilepsy. This limits the development of prophylactic therapies in epilepsy. Here, neural network dysfunctions reflected by oscillopathies and microepileptiform activities, including neuronal hyperexcitability and hypersynchrony, drawn from both clinical and experimental epilepsy models, have been reviewed. This review suggests that epileptogenesis reflects a progressive and dynamic dysfunction of specific neuronal networks which recruit further interconnected groups of neurons, with this resultant pathological network mediating seizure occurrence, recurrence, and progression. In the future, combining spatial and temporal resolution of neuronal non-invasive recordings from patients at risk of developing epilepsy, together with analytics and computational tools, may contribute to determining whether the brain is undergoing epileptogenesis in asymptomatic patients following brain injury.
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Affiliation(s)
- Esther Pototskiy
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA; College of Sciences, Old Dominion University, Norfolk, Virginia
| | - Joshua Ryan Dellinger
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA
| | - Stuart Bumgarner
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA
| | - Jay Patel
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA
| | - William Sherrerd-Smith
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA
| | - Alberto E Musto
- Department of Anatomy & Pathology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA; Department of Neurology, Eastern Virginia Medical School, Department of Pathology, Norfolk, Virginia, USA.
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Yu T, Liu X, Sun L, Wu J, Wang Q. Clinical characteristics of post-traumatic epilepsy and the factors affecting the latency of PTE. BMC Neurol 2021; 21:301. [PMID: 34348691 PMCID: PMC8340486 DOI: 10.1186/s12883-021-02273-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/09/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives To summarize the clinical characteristics of post-traumatic epilepsy (PTE), and to identify the factors affecting the latency of PTE after traumatic brain injury (TBI). Methods We conducted a retrospective clinical analysis in patients with PTE who visited the outpatient Department of Epilepsy, Beijing Tiantan Hospital from January 2013 to December 2018. The clinical characteristics, including gender, age distribution, seizure type, and latency were summarized. Factors affecting the latency of PTE were evaluated using Kaplan-Meier curves and Cox proportional hazard regression analysis. Results Complete clinical information was available for 2862 subjects, of which 78.48% were males. The mean age at TBI was 21.4 ± 15.1 years and peaked in the 0 to 12-year-old and 15 to 27-year-old groups. Generalized onset seizure was the most frequent seizure type (72.82% of patients). Approximately 19.95% PTE patients developed drug-resistant epilepsy. The latency of PTE ranged from 8 days to 20 years, with a median of 24.0 (IQR, 5.0–84.0) months. The Kaplan-Meier curves demonstrated that gender, age at TBI, severity of TBI, multiple craniocerebral injuries, post-TBI treatments, acute seizures, and residual disability were associated with PTE latency. The Cox regression model indicated that age ≥ 18 years old, severe TBI with multiple surgical operations, acute seizures, and residual disability were risk factors for shorter PTE latency. Conclusions PTE is more common in males than females, and peaked in the 0 to 12-year-old and 15 to 27-year-old groups. Generalized onset seizure was the most common seizure type and 19.95% of participants developed drug-resistant epilepsy. Patients aged ≥18 years old, who suffered severe TBI followed by multiple surgical operations, experienced acute seizures, or with residual disabilities had shorter PTE latency.
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Affiliation(s)
- Tingting Yu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P. R. China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, P. R. China
| | - Xiao Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P. R. China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, P. R. China
| | - Lei Sun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P. R. China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, P. R. China
| | - Jianping Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P. R. China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, P. R. China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, 100070, P. R. China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, P. R. China. .,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, P. R. China. .,Beijing Institute for Brain Disorders, Beijing, 100069, P. R. China.
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Butler E, Mills N, J P Alix J, Hart AR. Knowledge and attitudes of critical care providers towards neurophysiological monitoring, seizure diagnosis, and treatment. Dev Med Child Neurol 2021; 63:976-983. [PMID: 33913148 DOI: 10.1111/dmcn.14907] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
AIM To explore the attitudes of paediatric intensive care unit (PICU) health care professionals towards diagnosis and neurophysiological monitoring of seizures. METHOD This study used an explanatory sequential mixed-methods approach, interconnecting quantitative and qualitative features, comprising questionnaires and interviews, with equal weighting between stages, of health care professionals working in UK PICUs. Interview data were analysed using thematic analysis and triangulated with questionnaire data. RESULTS Seventy-two questionnaires were returned: 49 out of 60 (71.0%) of respondents reported that seizures were extremely hard or somewhat hard to diagnose in a critically ill child, and 81.2% had seen misdiagnosis occur. Thematic analysis revealed two main themes: (1) feeling out of control when faced with 'grey areas'; and (2) regaining control, which compromised three subthemes: aggressive intervention, accurate diagnosis, and eschewing diagnosis. INTERPRETATION Health care professionals find accurate diagnosis of seizures difficult, particularly in sedated/paralysed children and those with chronic neurological disorders. They report they would like better educational opportunities on discriminating between epileptic and non-epileptic events to improve their confidence. Professionals want routine neurophysiological monitoring that can be applied and interpreted at the bedside throughout the day to regain a sense of control over their patient, direct treatment appropriately, and, potentially, improve outcomes, but report appropriate training and peer review are essential if it is to be introduced into routine care. What this study adds Paediatric intensive care unit (PICU) staff feel out of control when faced with diagnosing seizures. Neurophysiological monitoring is wanted to help diagnosis and treatment. Amplitude-integrated electroencephalography is the preferred, pragmatic tool by PICU staff.
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Affiliation(s)
- Evie Butler
- University of Sheffield Medical School, Sheffield, UK
| | - Nicholas Mills
- Department of Paediatric Intensive Care Unit, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - James J P Alix
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Anthony R Hart
- Department of Paediatric and Neonatal Neurology, Ryegate Children's Centre, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Wang XP, Zhong J, Lei T, Wang HJ, Zhu LN, Chu S, Chen D, Liu L. Development and external validation of a predictive nomogram model of posttraumatic epilepsy: A retrospective analysis. Seizure 2021; 88:36-44. [PMID: 33812306 DOI: 10.1016/j.seizure.2021.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/20/2021] [Accepted: 03/22/2021] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE We aimed to develop and validate a predictive model of posttraumatic epilepsy (PTE). METHODS The training cohort was patients registered at West China Hospital and diagnosed as traumatic brain injury (TBI) between January 1, 2011, and December 31, 2017. On the basis of multivariable cox proportional hazards model using a forward stepwise method, the nomogram was generated. We externally validated this instrument in 834 participants from two independent cohorts to assess its performance. RESULTS The nomogram was built based on the results of multivariable cox proportional hazards regression analysis of 1301patients from West China Hospital. The prevalence of PTE was 12.8% (95% confidence interval [CI], 10.9-14.6%) in training cohort, 10.5% (95% CI, 7.5-13.4%) in the testing 1 cohort, and 6.1% (95% CI, 3.7-8.4%) in the testing 2 cohort. 7 independent predictors of PTE composed the nomogram (sex, time of loss of consciousness, subdural hemorrhage, contusion sites, early posttraumatic seizures, TBI severity, and treatment). The C-index was 0.846 (95% CI, 0.817-0.876), and the corresponding sensitivity and specificity were 0.867 and 0.738. External validations showed good discrimination in overall testing cohorts with a C-index of 0.895 (95% CI, 0.859-0.930), in the testing 1 cohort (C-index 0.897, 95% CI, 0.855-0.938) and testing 2 cohort (C-index, 0.883, 95% CI, 0.814-0.952). Calibration of this model was also good since the calibration plots were close to the ideal line. CONCLUSIONS This nomogram was developed and validated in a large cohort for individualized prediction of PTE, which can identify individuals at high risk of epilepsy and help us find preventive drugs based on these targeted population.
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Affiliation(s)
- Xue-Ping Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Jie Zhong
- Department of Ophthalmology, Sichuan Provincial People's Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China
| | - Ting Lei
- Department of Neurosurgery, Shang Jin Nan Fu Hospital of West China Hospital, Sichuan University, No. 253, Shang Jin Road, Chengdu, 610041, Sichuan Province, China
| | - Hai-Jiao Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Li-Na Zhu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Shanshan Chu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China.
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Alterations in coordinated EEG activity precede the development of seizures in comatose children. Clin Neurophysiol 2021; 132:1505-1514. [PMID: 34023630 DOI: 10.1016/j.clinph.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/21/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to test the hypothesis that computational features of the first several minutes of EEG recording can be used to estimate the risk for development of acute seizures in comatose critically-ill children. METHODS In a prospective cohort of 118 comatose children, we computed features of the first five minutes of artifact-free EEG recording (spectral power, inter-regional synchronization and cross-frequency coupling) and tested if these features could help identify the 25 children who went on to develop acute symptomatic seizures during the subsequent 48 hours of cEEG monitoring. RESULTS Children who developed acute seizures demonstrated higher average spectral power, particularly in the theta frequency range, and distinct patterns of inter-regional connectivity, characterized by greater connectivity at delta and theta frequencies, but weaker connectivity at beta and low gamma frequencies. Subgroup analyses among the 97 children with the same baseline EEG background pattern (generalized slowing) yielded qualitatively and quantitatively similar results. CONCLUSIONS These computational features could be applied to baseline EEG recordings to identify critically-ill children at high risk for acute symptomatic seizures. SIGNIFICANCE If confirmed in independent prospective cohorts, these features would merit incorporation into a decision support system in order to optimize diagnostic and therapeutic management of seizures among comatose children.
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Machine learning models to predict electroencephalographic seizures in critically ill children. Seizure 2021; 87:61-68. [PMID: 33714840 DOI: 10.1016/j.seizure.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine whether machine learning techniques would enhance our ability to incorporate key variables into a parsimonious model with optimized prediction performance for electroencephalographic seizure (ES) prediction in critically ill children. METHODS We analyzed data from a prospective observational cohort study of 719 consecutive critically ill children with encephalopathy who underwent clinically-indicated continuous EEG monitoring (CEEG). We implemented and compared three state-of-the-art machine learning methods for ES prediction: (1) random forest; (2) Least Absolute Shrinkage and Selection Operator (LASSO); and (3) Deep Learning Important FeaTures (DeepLIFT). We developed a ranking algorithm based on the relative importance of each variable derived from the machine learning methods. RESULTS Based on our ranking algorithm, the top five variables for ES prediction were: (1) epileptiform discharges in the initial 30 minutes, (2) clinical seizures prior to CEEG initiation, (3) sex, (4) age dichotomized at 1 year, and (5) epileptic encephalopathy. Compared to the stepwise selection-based approach in logistic regression, the top variables selected by our ranking algorithm were more informative as models utilizing the top variables achieved better prediction performance evaluated by prediction accuracy, AUROC and F1 score. Adding additional variables did not improve and sometimes worsened model performance. CONCLUSION The ranking algorithm was helpful in deriving a parsimonious model for ES prediction with optimal performance. However, application of state-of-the-art machine learning models did not substantially improve model performance compared to prior logistic regression models. Thus, to further improve the ES prediction, we may need to collect more samples and variables that provide additional information.
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Elsamadicy AA, Koo AB, David WB, Lee V, Zogg CK, Kundishora AJ, Hong C, Reeves BC, Sarkozy M, Kahle KT, DiLuna M. Post-traumatic seizures following pediatric traumatic brain injury. Clin Neurol Neurosurg 2021; 203:106556. [PMID: 33636505 DOI: 10.1016/j.clineuro.2021.106556] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 01/26/2021] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the national impact of demographic, hospital, and inpatient risk factors on post-traumatic seizure (PTS) development in pediatric patients who presented to the ED following a traumatic brain injury (TBI). PATIENTS AND METHODS The Nationwide Emergency Department Sample database years 2010-2014 was queried. Patients (<21 years old) with a primary diagnosis of TBI and subsequent secondary diagnosis of PTS were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. We identified demographic variables, hospital characteristics, pre-existing medical comorbidities, etiology of injuries, and type of injury. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with post-traumatic seizures. RESULTS We identified 1,244,087 patients who sustained TBI, of which 10,340 (0.83%) developed PTS. Of the patients who had seizures, the youngest cohort aged 0-5 years had the greatest proportion of seizure development (p < 0.001). Compared to those TBI patients with loss of consciousness (LOC), patients encountering no LOC after TBI had the smallest proportion of seizures while Prolonged LOC with baseline return had the greatest proportion. On univariate analysis of the effect of in-hospital complication on rate of seizures, respiratory, renal and urinary, hematoma, septicemia, and other neurological complications were all significantly associated with seizure development. On multivariate regression, age 6-10 years (OR: 0.48, p < 0.001) 11-15 years (OR: 0.41, p < 0.001), and 16-20 years (OR: 0.51, p < 0.001) were independently associated with decreased risk of developing seizures. Extended LOC with baseline return (OR: 6.33, p < 0.001), extended LOC without baseline return (OR: 1.95, p = 0.009), and Other LOC (OR: 3.02, p < 0.001) were independently associated with increased risk of developing seizures. Subarachnoid hemorrhage (OR: 4.14, p < 0.001), subdural hemorrhage [OR: 7.72, p < 0.001), and extradural hemorrhage (OR: 3.13, p < 0.001) were all independently associated with increased risk of developing seizures. CONCLUSION Out study demonstrates that various demographic, hospital, and clinical risk factors are associated with the development of seizures following traumatic brain injury. Enhancing awareness of these drivers may help provide greater awareness of patients likely to develop post-traumatic seizures such that this complication can be decreased in incidence so as to improve quality of care and decrease healthcare costs.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Victor Lee
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Cheryl K Zogg
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Christopher Hong
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States.
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Haque KD, Grinspan ZM, Mauer E, Nellis ME. Early Use of Antiseizure Medication in Mechanically Ventilated Traumatic Brain Injury Cases: A Retrospective Pediatric Health Information System Database Study. Pediatr Crit Care Med 2021; 22:90-100. [PMID: 33009357 PMCID: PMC8344024 DOI: 10.1097/pcc.0000000000002576] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of morbidity and mortality in children. Post-traumatic seizures occur in 25% of children with severe traumatic brain injury and may worsen outcomes. Our objective was to use a retrospective cohort study to examine the association between the early seizure occurrence and the choice of early antiseizure medication in children with traumatic brain injury. DESIGN Retrospective cohort study using the Pediatric Health Information Systems database, 2010-2017. SETTING Fifty-one U.S. children's hospitals. PATIENTS Children (< 18 yr old at admission) with diagnostic codes for traumatic brain injury who were mechanically ventilated at the time of admission and with hospital length of stay greater than 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 3,479 children were identified via coding and including in the analysis. Patients receiving antiseizure medication starting day 0 with levetiracetam were compared with those receiving phenytoin. The outcome was seizure occurrence, identified using validated International Classification of Diseases, 9th Revision, Clinical Modification and International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. The median (interquartile range) age of patients was 4 (1-11) years, and the most common mechanism of injury was motor vehicle accident, occurring in 960 of patients (27%). A total of 2,342 patients (67%) received levetiracetam on day 0 and 1,137 patients (33%) received phenytoin on day 0. Totally 875 patients (37%) receiving levetiracetam on day 0 developed seizures, compared with 471 patients (41%) receiving phenytoin on day 0 (p = 0.02). Upon multivariable analysis adjusting for age, injury by child abuse, subdural hemorrhage, ethnicity, and admission year, children receiving phenytoin on day 0 were 1.26 (95% CI, 1.07-1.48) times more likely to be associated with post-traumatic seizure occurrence, compared with children receiving levetiracetam on day 0 (p = 0.01). CONCLUSIONS Early administration of levetiracetam was associated with less-frequent seizure occurrence than early administration of phenytoin in mechanically ventilated children with traumatic brain injury. Additional studies are necessary to determine if the association is causal or due to unmeasured confounders and/or selection bias.
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Affiliation(s)
- Kelly D Haque
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Zachary M Grinspan
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
- Division of Pediatric Neurology, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Elizabeth Mauer
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
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Abstract
After convulsive status epilepticus, patients of all ages may have ongoing EEG seizures identified by continuous EEG monitoring. Furthermore, high EEG seizure exposure has been associated with unfavorable neurobehavioral outcomes. Thus, recent guidelines and consensus statements recommend many patients with persisting altered mental status after convulsive status epilepticus undergo continuous EEG monitoring. This review summarizes the available epidemiologic data and related recommendations provided by recent guidelines and consensus statements.
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Fung FW, Parikh DS, Jacobwitz M, Vala L, Donnelly M, Wang Z, Xiao R, Topjian AA, Abend NS. Validation of a model to predict electroencephalographic seizures in critically ill children. Epilepsia 2020; 61:2754-2762. [PMID: 33063870 DOI: 10.1111/epi.16724] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Electroencephalographic seizures (ESs) are common in encephalopathic critically ill children, but identification requires extensive resources for continuous electroencephalographic monitoring (CEEG). In a previous study, we developed a clinical prediction rule using three clinical variables (age, acute encephalopathy category, clinically evident seizure[s] prior to CEEG initiation) and two electroencephalographic (EEG) variables (EEG background category and interictal discharges within the first 30 minutes of EEG) to identify patients at high risk for ESs for whom CEEG might be essential. In the current study, we aimed to validate the ES prediction model using an independent cohort. METHODS The prospectively acquired validation cohort consisted of 314 consecutive critically ill children treated in the Pediatric Intensive Care Unit of a quaternary care referral hospital with acute encephalopathy undergoing clinically indicated CEEG. We calculated test characteristics using the previously developed prediction model in the validation cohort. As in the generation cohort study, we selected a 0.10 cutpoint to emphasize sensitivity. RESULTS The incidence of ESs in the validation cohort was 22%. The generation and validation cohorts were alike in most clinical and EEG characteristics. The ES prediction model was well calibrated and well discriminating in the validation cohort. The model had a sensitivity of 90%, specificity of 37%, positive predictive value of 28%, and negative predictive value of 93%. If applied, the model would limit 31% of patients from undergoing CEEG while failing to identify 10% of patients with ESs. The model had similar performance characteristics in the generation and validation cohorts. SIGNIFICANCE A model employing five readily available clinical and EEG variables performed well when validated in a new consecutive cohort. Implementation would substantially reduce CEEG utilization, although some patients with ESs would not be identified. This model may serve a critical role in targeting limited CEEG resources to critically ill children at highest risk for ESs.
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Affiliation(s)
- France W Fung
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Departments Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Darshana S Parikh
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Vala
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zi Wang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Xiao
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas S Abend
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Departments Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Fordington S, Manford M. A review of seizures and epilepsy following traumatic brain injury. J Neurol 2020; 267:3105-3111. [PMID: 32444981 PMCID: PMC7501105 DOI: 10.1007/s00415-020-09926-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is one of the commonest presentations to emergency departments and is associated with seizures carrying different significance at different stages following injury. We describe the epidemiology of early and late seizures following TBI, the significance of intracranial haemorrhage of different types in the risk of later epilepsy and the gaps in current understanding of risk factors contributing to the risk of post-traumatic epilepsy (PTE). The delay from injury to epilepsy presents an opportunity to understand the mechanisms underlying changes in the brain and how they may reveal potential targets for anti-epileptogenic therapy. We review existing treatments, both medical and surgical and conclude that current research is not tailored to differentiate between PTE and other forms of focal epilepsy. Finally, we review the increasing understanding of the frequency and significance of dissociative seizures following mild TBI.
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Affiliation(s)
| | - Mark Manford
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK.
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Fung FW, Fan J, Vala L, Jacobwitz M, Parikh DS, Donnelly M, Topjian AA, Xiao R, Abend NS. EEG monitoring duration to identify electroencephalographic seizures in critically ill children. Neurology 2020; 95:e1599-e1608. [PMID: 32690798 DOI: 10.1212/wnl.0000000000010421] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 04/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To determine the optimal duration of continuous EEG monitoring (CEEG) for electrographic seizure (ES) identification in critically ill children. METHODS We performed a prospective observational cohort study of 719 consecutive critically ill children with encephalopathy. We evaluated baseline clinical risk factors (age and prior clinically evident seizures) and emergent CEEG risk factors (epileptiform discharges and ictal-interictal continuum patterns) using a multistate survival model. For each subgroup, we determined the CEEG duration for which the risk of ES was <5% and <2%. RESULTS ES occurred in 184 children (26%). Patients achieved <5% risk of ES after (1) 6 hours if ≥1 year without prior seizures or EEG risk factors; (2) 1 day if <1 year without prior seizures or EEG risks; (3) 1 day if ≥1 year with either prior seizures or EEG risks; (4) 2 days if ≥1 year with prior seizures and EEG risks; (5) 2 days if <1 year without prior seizures but with EEG risks; and (6) 2.5 days if <1 year with prior seizures regardless of the presence of EEG risks. Patients achieved <2% risk of ES at the same durations except patients without prior seizures or EEG risk factors would require longer CEEG (1.5 days if <1 year of age, 1 day if ≥1 year of age). CONCLUSIONS A model derived from 2 baseline clinical risk factors and emergent EEG risk factors would allow clinicians to implement personalized strategies that optimally target limited CEEG resources. This would enable more widespread use of CEEG-guided management as a potential neuroprotective strategy. CLINICALTRIALSGOV IDENTIFIER NCT03419260.
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Affiliation(s)
- France W Fung
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia.
| | - Jiaxin Fan
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lisa Vala
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Marin Jacobwitz
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Darshana S Parikh
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maureen Donnelly
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Alexis A Topjian
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Rui Xiao
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nicholas S Abend
- From the Department of Anesthesia and Critical Care Medicine (D.S.P., A.A.T.), Department of Pediatrics, Division of Neurology (F.W.F., M.J., D.S.P., N.S.A.), and Department of Neurodiagnostics (L.V., M.D., N.S.A.), Children's Hospital of Philadelphia; and Departments of Neurology (N.S.A., F.W.F.), Pediatrics (N.S.A., F.W.F.), Anesthesia and Critical Care (A.A.T., N.S.A.), and Biostatistics, Epidemiology and Informatics (J.F., R.X., N.S.A.), University of Pennsylvania Perelman School of Medicine, Philadelphia
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Griffith JL, Tomko ST, Guerriero RM. Continuous Electroencephalography Monitoring in Critically Ill Infants and Children. Pediatr Neurol 2020; 108:40-46. [PMID: 32446643 DOI: 10.1016/j.pediatrneurol.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.
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Affiliation(s)
- Jennifer L Griffith
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.
| | - Stuart T Tomko
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Réjean M Guerriero
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Fung FW, Jacobwitz M, Parikh DS, Vala L, Donnelly M, Fan J, Xiao R, Topjian AA, Abend NS. Development of a model to predict electroencephalographic seizures in critically ill children. Epilepsia 2020; 61:498-508. [PMID: 32077099 DOI: 10.1111/epi.16448] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Electroencephalographic seizures (ESs) are common in encephalopathic critically ill children, but ES identification with continuous electroencephalography (EEG) monitoring (CEEG) is resource-intense. We aimed to develop an ES prediction model that would enable clinicians to stratify patients by ES risk and optimally target limited CEEG resources. We aimed to determine whether incorporating data from a screening EEG yielded better performance characteristics than models using clinical variables alone. METHODS We performed a prospective observational study of 719 consecutive critically ill children with acute encephalopathy undergoing CEEG in the pediatric intensive care unit of a quaternary care institution between April 2017 and February 2019. We identified clinical and EEG risk factors for ES. We evaluated model performance with area under the receiver-operating characteristic (ROC) curve (AUC), validated the optimal model with the highest AUC using a fivefold cross-validation, and calculated test characteristics emphasizing high sensitivity. We applied the optimal operating slope strategy to identify the optimal cutoff to define whether a patient should undergo CEEG. RESULTS The incidence of ES was 26%. Variables associated with increased ES risk included age, acute encephalopathy category, clinical seizures prior to CEEG initiation, EEG background, and epileptiform discharges. Combining clinical and EEG variables yielded better model performance (AUC 0.80) than clinical variables alone (AUC 0.69; P < .01). At a 0.10 cutoff selected to emphasize sensitivity, the optimal model had a sensitivity of 92%, specificity of 37%, positive predictive value of 34%, and negative predictive value of 93%. If applied, the model would limit 29% of patients from undergoing CEEG while failing to identify 8% of patients with ES. SIGNIFICANCE A model employing readily available clinical and EEG variables could target limited CEEG resources to critically ill children at highest risk for ES, making CEEG-guided management a more viable neuroprotective strategy.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marin Jacobwitz
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Darshana S Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Vala
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jiaxin Fan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rui Xiao
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Neurodiagnostics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Semple BD, Dill LK, O'Brien TJ. Immune Challenges and Seizures: How Do Early Life Insults Influence Epileptogenesis? Front Pharmacol 2020; 11:2. [PMID: 32116690 PMCID: PMC7010861 DOI: 10.3389/fphar.2020.00002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/03/2020] [Indexed: 12/16/2022] Open
Abstract
The development of epilepsy, a process known as epileptogenesis, often occurs later in life following a prenatal or early postnatal insult such as cerebral ischemia, stroke, brain trauma, or infection. These insults share common pathophysiological pathways involving innate immune activation including neuroinflammation, which is proposed to play a critical role in epileptogenesis. This review provides a comprehensive overview of the latest preclinical evidence demonstrating that early life immune challenges influence neuronal hyperexcitability and predispose an individual to later life epilepsy. Here, we consider the range of brain insults that may promote the onset of chronic recurrent spontaneous seizures at adulthood, spanning intrauterine insults (e.g. maternal immune activation), perinatal injuries (e.g. hypoxic–ischemic injury, perinatal stroke), and insults sustained during early postnatal life—such as fever-induced febrile seizures, traumatic brain injuries, infections, and environmental stressors. Importantly, all of these insults represent, to some extent, an immune challenge, triggering innate immune activation and implicating both central and systemic inflammation as drivers of epileptogenesis. Increasing evidence suggests that pro-inflammatory cytokines such as interleukin-1 and subsequent signaling pathways are important mediators of seizure onset and recurrence, as well as neuronal network plasticity changes in this context. Our current understanding of how early life immune challenges prime microglia and astrocytes will be explored, as well as how developmental age is a critical determinant of seizure susceptibility. Finally, we will consider the paradoxical phenomenon of preconditioning, whereby these same insults may conversely provide neuroprotection. Together, an improved appreciation of the neuroinflammatory mechanisms underlying the long-term epilepsy risk following early life insults may provide insight into opportunities to develop novel immunological anti-epileptogenic therapeutic strategies.
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Affiliation(s)
- Bridgette D Semple
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Larissa K Dill
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Neurology, Alfred Health, Melbourne, VIC, Australia
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Thome JG, Reeder EL, Collins SM, Gopalan P, Robson MJ. Contributions of Interleukin-1 Receptor Signaling in Traumatic Brain Injury. Front Behav Neurosci 2020; 13:287. [PMID: 32038189 PMCID: PMC6985078 DOI: 10.3389/fnbeh.2019.00287] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/16/2019] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) in various forms affects millions in the United States annually. There are currently no FDA-approved therapies for acute injury or the chronic comorbidities associated with TBI. Acute phases of TBI are characterized by profound neuroinflammation, a process that stimulates the generation and release of proinflammatory cytokines including interleukin-1α (IL-1α) and IL-1β. Both forms of IL-1 initiate signaling by binding with IL-1 receptor type 1 (IL-1R1), a receptor with a natural, endogenous antagonist dubbed IL-1 receptor antagonist (IL-1Ra). The recombinant form of IL-1Ra has gained FDA approval for inflammatory conditions such as rheumatoid arthritis, prompting interest in repurposing these pharmacotherapies for other inflammatory diseases/injury states including TBI. This review summarizes the currently available preclinical and clinical literature regarding the therapeutic potential of inhibiting IL-1-mediated signaling in the context of TBI. Additionally, we propose specific research areas that would provide a greater understanding of the role of IL-1 signaling in TBI and how these data may be beneficial for the development of IL-1-targeted therapies, ushering in the first FDA-approved pharmacotherapy for acute TBI.
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Affiliation(s)
- Jason G Thome
- Department of Anesthesia and Critical Care, Division of Biological Sciences, College of Medicine, University of Chicago, Chicago, IL, United States
| | - Evan L Reeder
- Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Sean M Collins
- Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Poornima Gopalan
- Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Matthew J Robson
- Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
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42
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Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav 2019; 101:106409. [PMID: 31420288 DOI: 10.1016/j.yebeh.2019.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Pediatric status epilepticus carries a substantial risk for morbidity and mortality, but the relationship between seizure burden, treatment, and outcome remains incompletely understood. This review summarizes the evidence linking seizure burden and outcomes among critically ill children in the intensive care unit (ICU), a population in whom accurate quantification of seizure burden is possible using continuous electroencephalographic monitoring. Several high-quality observational studies among critically ill children have reported an association between higher seizure burden and worse outcome, even after adjusting for potential confounders such as age, etiology, and illness severity. Although these studies support the hypothesis that seizures contribute to brain injury and worsen outcome, a causal link between seizures and outcome remains to be proven. The relationship between seizures and outcome is likely complex, and dependent on factors such as etiology, preexisting neurological disability, medication exposure, and possibly individual genetic factors. Studies attempting to define this complex relationship will need to measure and account for these factors in their analyses. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Oh A, Olson LD, Chern JJ, Kim H. Clinical Characteristics and Nonconvulsive Seizures in Young Children With Abusive Head Trauma. J Child Neurol 2019; 34:713-719. [PMID: 31185789 DOI: 10.1177/0883073819853973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM We aimed to evaluate putative predictors of symptoms and signs at admission for nonconvulsive seizure and to examine the impact of nonconvulsive seizures on short-term outcomes. METHOD We retrospectively collected consecutive abusive head trauma patients (<36 months of age) from the trauma registry at Children's Healthcare of Atlanta between 2009 and 2014. Multiple logistic regression was performed to assess the putative predictors for the occurrence of nonconvulsive seizures including clinical seizures, altered mental status, respiratory difficulty, and cardiac arrest at admission, while controlling for age, sex, and injury severity. The Mann-Whitney U test and the Fisher exact test were used to compare the short-term outcomes between patients with and without nonconvulsive seizures. RESULTS Two hundred seventy patients with abusive head trauma were identified (male = 55.6%). The median age was 4 months (interquartile range = 2-8 months). Among 70 patients who underwent continuous electroencephalography (EEG), 40 had nonconvulsive seizures (57%) and 21 developed nonconvulsive status epilepticus (30%). Altered mental status at admission was associated with the occurrence of nonconvulsive seizures (odds ratio = 6.8, 95% confidence interval = 1.2-38.2, P = .03). Comparing patients with no seizures, those with nonconvulsive seizures were more likely to stay longer at hospital (9 days vs 14 days, P = .04) and to need rehabilitation (50.0% vs 63.2%, P = .03). CONCLUSIONS Nonconvulsive seizures and nonconvulsive status epilepticus was highly prevalent in young pediatric patients with abusive head trauma. Presenting with altered mental status at admission was found to predict the occurrence of nonconvulsive seizures. Nonconvulsive seizures had an unfavorable impact on short-term outcomes.
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Affiliation(s)
- Ahyuda Oh
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Larry D Olson
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,2 Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua J Chern
- 2 Children's Healthcare of Atlanta, Atlanta, GA, USA.,3 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hyunmi Kim
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,2 Children's Healthcare of Atlanta, Atlanta, GA, USA.,4 Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Villasana LE, Peters A, McCallum R, Liu C, Schnell E. Diazepam Inhibits Post-Traumatic Neurogenesis and Blocks Aberrant Dendritic Development. J Neurotrauma 2019; 36:2454-2467. [PMID: 30794026 DOI: 10.1089/neu.2018.6162] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Traumatic brain injury (TBI) triggers a robust increase in neurogenesis within the dentate gyrus of the hippocampus, but these new neurons undergo aberrant maturation and dendritic outgrowth. Because gamma-aminobutyric acid (GABA)A receptors (GABAARs) modulate dendritic outgrowth during constitutive neurogenesis and GABAAR-modulating sedatives are often administered to human patients after TBI, we investigated whether the benzodiazepine, diazepam (DZP), alters post-injury hippocampal neurogenesis. We used a controlled cortical impact (CCI) model of TBI in adult mice, and administered DZP or vehicle continuously for 1 week after injury via osmotic pump. Although DZP did not affect the neurogenesis rate in control mice, it almost completely prevented the TBI-induced increase in hippocampal neurogenesis as well as the aberrant dendritic growth of neurons born after TBI. DZP did not reduce cortical injury, reactive gliosis, or cell proliferation early after injury, but decreased c-Fos activation in the dentate gyrus at both early and late time-points after TBI, suggesting an association between neuronal activity and post-injury neurogenesis. Because DZP blocks post-injury neurogenesis, further studies are warranted to assess whether benzodiazepines alter cognitive recovery or the development of complications after TBI.
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Affiliation(s)
- Laura E Villasana
- 1Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Austin Peters
- 1Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Raluca McCallum
- 2Operative Care Division, VA Portland Health Care System, Portland, Oregon
| | - Chang Liu
- 1Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Eric Schnell
- 1Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon.,2Operative Care Division, VA Portland Health Care System, Portland, Oregon
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Ma SQ, Xu XX, He ZZ, Li XH, Luo JM. Dynamic changes in peripheral blood-targeted miRNA expression profiles in patients with severe traumatic brain injury at high altitude. Mil Med Res 2019; 6:12. [PMID: 31036067 PMCID: PMC6489315 DOI: 10.1186/s40779-019-0203-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this work is to detect and compare the peripheral blood miRNA expression profiles in patients with severe traumatic brain injury (sTBI) 2, 12, 24, 48, and 72 h after injury at high altitude and to predict the target genes of differential expressed miRNAs. METHODS Twenty sTBI patients from high-altitude areas were randomly selected according to the inclusion and exclusion criteria and were divided into five groups: the 2-h group, 12-h group, 24-h group, 48-h group, and 72-h group. Peripheral blood miRNA expression profiles were detected using real-time quantitative PCR (qRT-PCR). RESULTS The expression levels of miR-18a, miR-203, miR-146a, miR-149, miR-23b, and miR-let-7b in peripheral blood showed significant differences between the 2-h group and the 12-h group. The expression levels of miR-203, miR-146a, miR-149, miR-23b, and miR-let-7f in peripheral blood were up-regulated in the 24-h group. In the 48-h group, the expression levels of miR-181d, miR-29a, and miR-18b were upregulated. In the 72-h group, the expression levels of miR-203, miR-146a, miR-149, miR-23b, and miR-let-7f changed. The main target genes of the differentiation expressed miRNAs were genes that regulate inflammatory responses, apoptosis, and DNA damage/repair. CONCLUSIONS miRNAs may be involved in the pathogenesis of sTBI by dynamically regulating the target genes that regulate inflammatory responses, apoptosis, and DNA damage/repair pathways.
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Affiliation(s)
- Si-Qing Ma
- Department of Intensive Care Unit, Qinghai Provincial People's Hospital, Xining, 810007, China.
| | - Xue-Xia Xu
- Department of Intensive Care Unit, Qinghai Provincial People's Hospital, Xining, 810007, China
| | - Zong-Zhao He
- Department of Intensive Care Unit, Qinghai Provincial People's Hospital, Xining, 810007, China
| | - Xin-Hui Li
- Department of Intensive Care Unit, Qinghai Provincial People's Hospital, Xining, 810007, China
| | - Jun-Ming Luo
- Department of Pathology, Qinghai Provincial People's Hospital, Xining, 810007, China
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Zavadenko NN, Nesterovskiy YE, Kholin AA, Vorobyeva IS. [Cognitive and paroxysmal disorders in the long-term period of traumatic brain injury in children and adolescents]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:110-117. [PMID: 30778041 DOI: 10.17116/jnevro2019119011110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) clinical course and outcomes in children have peculiarities as the damage impacts brain, which growth and maturation are continuing. Thus, TBI interferes into normal processes of neuroontogenesis leading to negative consequences on the cognitive functions development, school education, social skills acquisition. Cognitive and behavioral disorders in children and adolescents in the long-term period of TBI become more prominent in co-occurrence with paroxysmal disorders, including posttraumatic headaches, posttraumatic epilepsy and subclinical epileptiform activity on the EEG. Therapeutic and rehabilitation procedures in in the long-term period of TBI in children and adolescents should be conducted not only during the first 12 months after injury, when they are expected to be the most efficient, but also later on taking into consideration continuing processes of the CNS morphological and functional maturation along with the high neuroplasticity of the developing brain.
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Affiliation(s)
- N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yu E Nesterovskiy
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Kholin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I S Vorobyeva
- Pirogov Russian National Research Medical University, Moscow, Russia
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Ketamine Alters Hippocampal Cell Proliferation and Improves Learning in Mice after Traumatic Brain Injury. Anesthesiology 2019; 129:278-295. [PMID: 29734230 DOI: 10.1097/aln.0000000000002197] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Traumatic brain injury induces cellular proliferation in the hippocampus, which generates new neurons and glial cells during recovery. This process is regulated by N-methyl-D-aspartate-type glutamate receptors, which are inhibited by ketamine. The authors hypothesized that ketamine treatment after traumatic brain injury would reduce hippocampal cell proliferation, leading to worse behavioral outcomes in mice. METHODS Traumatic brain injury was induced in mice using a controlled cortical impact injury, after which mice (N = 118) received either ketamine or vehicle systemically for 1 week. The authors utilized immunohistochemical assays to evaluate neuronal, astroglial, and microglial cell proliferation and survival 3 days, 2 weeks, and 6 weeks postintervention. The Morris water maze reversal task was used to assess cognitive recovery. RESULTS Ketamine dramatically increased microglial proliferation in the granule cell layer of the hippocampus 3 days after injury (injury + vehicle, 2,800 ± 2,700 cells/mm, n = 4; injury + ketamine, 11,200 ± 6,600 cells/mm, n = 6; P = 0.012). Ketamine treatment also prevented the production of astrocytes 2 weeks after injury (sham + vehicle, 2,400 ± 3,200 cells/mm, n = 13; injury + vehicle, 10,500 ± 11,300 cells/mm, n = 12; P = 0.013 vs. sham + vehicle; sham + ketamine, 3,500 ± 4,900 cells/mm, n = 14; injury + ketamine, 4,800 ± 3,000 cells/mm, n = 13; P = 0.955 vs. sham + ketamine). Independent of injury, ketamine temporarily reduced neurogenesis (vehicle-exposed, 105,100 ± 66,700, cells/mm, n = 25; ketamine-exposed, 74,300 ± 29,200 cells/mm, n = 27; P = 0.031). Ketamine administration improved performance in the Morris water maze reversal test after injury, but had no effect on performance in sham-treated mice. CONCLUSIONS Ketamine alters hippocampal cell proliferation after traumatic brain injury. Surprisingly, these changes were associated with improvement in a neurogenesis-related behavioral recall task, suggesting a possible benefit from ketamine administration after traumatic brain injury in mice. Future studies are needed to determine generalizability and mechanism.
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Fitzpatrick S, Leach P. Neurosurgical aspects of abusive head trauma management in children: a review for the training neurosurgeon. Br J Neurosurg 2018; 33:47-50. [PMID: 30353746 DOI: 10.1080/02688697.2018.1529295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The management of head trauma in children from suspected abuse is multidisciplinary. The primary role of neurosurgeons is to manage the acute clinical situation. They also have a secondary role in assisting others to determine the cause of the injury and prevent recurrences. This article aims to guide the trainee neurosurgeon on management of this patient group according to current literature.
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Affiliation(s)
- S Fitzpatrick
- a College of Medicine, University of Cardiff , Wales , UK
| | - P Leach
- b Department of Paediatric Neurosurgery , University Hospital of Wales , Cardiff , UK
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Abstract
PURPOSE OF REVIEW All critical care is directed at maintaining brain health, but recognizing neurologic complications of critical illness in children is difficult, and limited data exist to guide practice. This article discusses an approach to the recognition and management of seizures, stroke, and cardiac arrest as complications of other critical illnesses in the pediatric intensive care unit. RECENT FINDINGS Convulsive and nonconvulsive seizures occur frequently in children after cardiac arrest or traumatic brain injury and during extracorporeal membrane oxygenation. Seizures may add to neurologic morbidity, and continuous EEG monitoring is needed for up to 24 hours for detection. Hypothermia has not been shown to improve outcome after cardiac arrest in children, but targeted temperature management with controlled normothermia and prevention of fever is a mainstay of neuroprotection. SUMMARY Much of brain-directed pediatric critical care is empiric. Recognition of neurologic complications of critical illness requires multidisciplinary care, serial neurologic examinations, and an appreciation for the multiple risk factors for neurologic injury present in most patients in the pediatric intensive care unit. Through attention to the fundamentals of neuroprotection, including maintaining or restoring cerebral perfusion matched to the metabolic needs of the brain, combined with anticipatory planning, these complications can be prevented or the neurologic injury mitigated.
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Brady RD, Casillas-Espinosa PM, Agoston DV, Bertram EH, Kamnaksh A, Semple BD, Shultz SR. Modelling traumatic brain injury and posttraumatic epilepsy in rodents. Neurobiol Dis 2018; 123:8-19. [PMID: 30121231 DOI: 10.1016/j.nbd.2018.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/25/2018] [Accepted: 08/13/2018] [Indexed: 12/14/2022] Open
Abstract
Posttraumatic epilepsy (PTE) is one of the most debilitating and understudied consequences of traumatic brain injury (TBI). It is challenging to study the effects, underlying pathophysiology, biomarkers, and treatment of TBI and PTE purely in human patients for a number of reasons. Rodent models can complement human PTE studies as they allow for the rigorous investigation into the causal relationship between TBI and PTE, the pathophysiological mechanisms of PTE, the validation and implementation of PTE biomarkers, and the assessment of PTE treatments, in a tightly controlled, time- and cost-efficient manner in experimental subjects known to be experiencing epileptogenic processes. This article will review several common rodent models of TBI and/or PTE, including their use in previous studies and discuss their relative strengths, limitations, and avenues for future research to advance our understanding and treatment of PTE.
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Affiliation(s)
- Rhys D Brady
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia.
| | - Pablo M Casillas-Espinosa
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia.
| | - Denes V Agoston
- Anatomy, Physiology & Genetics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Edward H Bertram
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA 22908-0394, USA
| | - Alaa Kamnaksh
- Anatomy, Physiology & Genetics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Bridgette D Semple
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia
| | - Sandy R Shultz
- Departments of Neuroscience and Medicine, Central Clinical School, Monash University, VIC 3004, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC 3052, Australia
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