Neurologic outcome of postanoxic refractory status epilepticus after aggressive treatment

Care pathways for individuals with post-anoxic disorder of consciousness (CaPIADoC): an inter-society Consensus Conference

BACKGROUND

Accurate recognition of consciousness level and detection of neurological complications since the intensive care unit are crucial for an appropriate prognostication and tailored treatment in patients with post-anoxic disorder of consciousness (DoC).

OBJECTIVE

The present inter-society Consensus Conference aimed at addressing current debates on diagnostic and prognostic procedures.

METHODS

Twelve working groups involving 22 multidisciplinary professionals (membership of 9 Scientific Societies and 2 patients' family Associations) conducted a systematic literature review focused on 12 questions addressing diagnosis (n = 5) and prognosis (n = 7). The quality of evidence of the included studies was evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. A Jury involving Scientific Societies and patients' family Associations provided recommendations based on the evidence levels and expert opinion.

RESULTS

An overall number of 1,219 papers was screened, and 21 were included in the review. Working groups produced a report on strengths and limits of evidence for each question. The overall suggestion was to use a multimodal assessment combining validated clinical scales, neurophysiological exams, and neuroimaging in diagnostic and prognostic procedure, to guide personalized treatment. A strong recommendation was to use standardized terminologies and diagnostic criteria for ensuring homogeneity and appropriateness in patients management.

CONCLUSION

This multidisciplinary Consensus Conference provided the first operational recommendations for a good clinical practice procedure for patients with post-anoxic DoC. A periodic review will be necessary based on future evidence from the literature and implementation of the present recommendations.

Electrographic and Clinical Determinants of Good Outcome After Postanoxic Status Epilepticus

BACKGROUND AND OBJECTIVES

Postanoxic electrographic status epilepticus (PSE) affects up to a third of all comatose patients after cardiac arrest (CA) and is associated with high mortality. Late PSE onset (>24 hours), from a restored continuous background pattern, and absence of established indicators of poor outcome at multimodal prognostication are described in survivors. We aimed to determine the increase in probability of good long-term outcome after PSE in patients presenting with this favorable PSE profile compared with all patients with PSE.

METHODS

This is a prospective observational substudy of the international Targeted Hypothermia vs Targeted Normothermia After Out-of-Hospital Cardiac Arrest trial (TTM2-trial, 2017-2020) including adult comatose patients resuscitated from CA with continuous EEG (cEEG) monitoring. EEG background pattern and type of PSE were determined using standardized EEG terminology of the American Clinical Neurophysiology Society, blinded to clinical data. On day 4, multimodal prognostication was performed according to the European postresuscitation guidelines. Good outcome was defined as a modified Rankin Scale score of 0-3 at 6 months. Detailed follow-up was performed at 6 and 24 months.

RESULTS

A total of 191 patients were monitored with cEEG, of whom 52 (27%) developed possible or definite PSE at a median of 42 hours [IQR 32-46] after CA. The median age was 70 (IQR 63-77) years, and 35% were female. Favorable PSE profile was present in 20 patients (38%), of whom 12 patients (60%) survived until 6 months and 8 (40%) had good outcome; thus, the probability of good outcome increased 2.7 times. All patients lacking a favorable PSE profile had poor outcome. All patients with good outcome obeyed commands within the first 7 days. At 24 months, all 12 survivors were still alive and 7 had good functional outcome. Detailed follow-up at 24 months showed that most had only mild cognitive impairment and overall life satisfaction was similar to the general population.

DISCUSSION

PSE is compatible with good outcome when onset is late and from a continuous background and no established indicators of poor outcome are present. One-third of patients with PSE had favorable PSE profile, of whom well over a third eventually had good outcome and showed improved level of consciousness within the first week.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT02908308.

Myoclonus After Cardiac Arrest did not Correlate with Cortical Response on Somatosensory Evoked Potentials

PurposeMyoclonus after anoxic brain injury is a marker of significant cerebral injury. Absent cortical signal (N20) on somatosensory evoked potentials (SSEPs) after cardiac arrest is a reliable predictor of poor neurological recovery when combined with an overall clinical picture consistent with severe widespread neurological injury. We evaluated a clinical question of if SSEP result could be predicted from other clinical and neurodiagnostic testing results in patients with post-anoxic myoclonus.MethodsRetrospective chart review of all adult patients with post-cardiac arrest myoclonus who underwent both electroencephalographic (EEG) monitoring and SSEPs for neuroprognostication. Myoclonus was categorized as "non-myoclonic movements," "myoclonus not captured on EEG," "myoclonus without EEG correlate," "myoclonus with EEG correlate," and "status myoclonus." SSEP results were categorized as all absent, all present, N18 and N20 absent bilaterally, and N20 only absent bilaterally. Cox proportional hazards with censoring was used to evaluate the association of myoclonus category, SSEP results, and confounding factors with survival.ResultsIn 56 patients, median time from arrest to either confirmed death or last follow up was 9 days. The category of myoclonus was not associated with SSEP result or length of survival. Absence of N20 s or N18 s was associated with shorter survival (N20 hazard ratio [HR] 4.4, p = 0.0014; N18 HR 5.5, p < 0.00001).ConclusionsCategory of myoclonus did not reliably predict SSEP result. SSEP result was correlated with outcome consistently, but goals of care transitioned to comfort measures only in all patients with present peripheral potentials and either absent N20 s only or absence of N18 s and N20 s. Our results suggest that SSEPs may retain prognostic value in patients with post-anoxic myoclonus.

Prolonged Monitoring of Brain Electrical Activity in the Intensive Care Unit

Electroencephalography (EEG) has been used to assess brain electrical activity for over a century. More recently, technological advancements allowed EEG to be a widely available and powerful tool in the intensive care unit (ICU), where patients at risk for cerebral dysfunction and brain injury can be monitored in a continuous, real-time manner. In the last 2 decades, several organizations established guidelines for continuous EEG monitoring in the ICU, defining critical care EEG terminology and technical standards for technicians, machines, and electroencephalographers. This article provides an overview of the current role of continuous EEG monitoring in the ICU.

Myoclonus After Cardiac Arrest: Need for Standardization-A Systematic Review and Research Proposal on Terminology

OBJECTIVES

Although myoclonus less than or equal to 72 hours after cardiac arrest (CA) is often viewed as a single entity, there is considerable heterogeneity in its clinical and electrophysiology characteristics, and its strength of association with outcome. We reviewed definitions, electroencephalogram, and outcome of myoclonus post-CA to assess the need for consensus and the potential role of electroencephalogram for further research.

DATA SOURCES

PubMed, Embase, and Cochrane databases.

STUDY SELECTION

English-language adult (≥ 18 yr) studies from 1966 to May 31, 2024, reporting myoclonus, myoclonic status/status myoclonus (MyS/SM), myoclonic status epilepticus (MSE), and/or early Lance-Adams Syndrome (eLAS) less than or equal to 72 hours post-CA. All study designs were independently screened by two authors.

DATA EXTRACTION

Data on patients presenting myoclonus, MyS/SM, MSE, and eLAS less than or equal to 72 hours post-CA, along with their definitions, electroencephalogram, and outcomes were extracted. The Newcastle-Ottawa Scale and Cochrane-Risk-of-Bias Assessment tool were used to evaluate study quality (PROSPERO n.CRD42023438107).

DATA SYNTHESIS

Of 585 identified articles, 119 met the inclusion criteria, revealing substantial heterogeneity in definitions, electroencephalogram, and outcomes. Among 3881 patients, myoclonus was reported in 2659, MyS/SM in 883, MSE in 569, and eLAS in 40. Among patients with a defined outcome, a Cerebral Performance Category (CPC) scale of 1-2 was reported in 9.8% of patients with myoclonus, 5.8% with MyS/SM, 5.7% with MSE, and 82.0% with eLAS. Electroencephalogram was recorded in 2714 patients (69.9%). CPC of 1-2 was observed in 1.6% of patients with suppression/suppression burst (SB)/unreactive (U) electroencephalogram, 11.3% with non-SB/U electroencephalogram and status epilepticus (SE), and 22.3% with non-SB/U electroencephalogram without SE.

CONCLUSIONS

Heterogeneity in definitions resulted in weak associations with outcomes. We propose to investigate myoclonus by including related electroencephalogram patterns: myoclonus associated with suppression/SB background electroencephalogram, myoclonus with nonsuppression/SB background but SE-electroencephalogram, and myoclonus with nonsuppression/SB background without SE-electroencephalogram. This pragmatic research approach should be validated in future studies.

Epileptiform Electrographic Patterns After Cardiac Arrest: Give Up or Treat?

This Viewpoint challenges conventional clinical practice that eschews pharmacological intervention for comatose patients with epileptiform abnormalities after cardiac arrest using evidence from the Treatment of Electroencephalographic Status Epilepticus after Cardiopulmonary Resuscitation (TELSTAR) trial.

Refractory and Super-Refractory Status Epilepticus: Therapeutic Options and Prognosis

In patients with status epilepticus (SE), the underlying biologic background represents the main prognostic variable. A swift application of a treatment protocol is recommended, including adequate doses of a benzodiazepine followed by an intravenous anti-seizure medicine. If refractory SE arises, general anesthetics should be used in generalized convulsive and non-convulsive SE in coma, while further non-sedating anti-seizure medications attempts are warranted in patients with focal forms. Ketogenic diet and/or ketamine in patients with super-refractory SE, and immunologic treatments for those with new-onset refractory SE/febrile-induced refractory epilepsy syndrome should be considered early. Pharmacologic treatment of SE after cardiac arrest should be oriented by the results of multimodal prognostication.

Personalized neuron-specific enolase level based on EEG pattern for prediction of poor outcome after cardiac arrest

BACKGROUND

After cardiac arrest (CA), the European recommendations suggest to use a neuron-specific enolase (NSE) level > 60 µg/L at 48-72 h to predict poor outcome. However, the prognostic performance of NSE can vary depending on electroencephalogram (EEG). The objective was to determine whether the NSE threshold which predicts poor outcome varies according to EEG patterns and the effect of electrographic seizures on NSE level.

METHODS

A retrospective study was conducted in a tertiary CA center, using a prospective registry of 155 adult patients comatose 72 h after CA. EEG patterns were classified according to the Westhall classification (benign, malignant or highly malignant). Neurological outcome was evaluated using the CPC scale at 3 months (CPC 3-5 defining a poor outcome).

RESULTS

Participants were 64 years old (IQR [53; 72,5]), and 74% were male. 83% were out-of-hospital CA and 48% were initial shockable rhythm. Electrographic seizures were observed in 5% and 8% of good and poor outcome patients, respectively (p = 0.50). NSE blood levels were significantly lower in the good outcome (median 20 µg/L IQR [15; 30]) compared to poor outcome group (median 110 µg/l IQR [49;308], p < 0,001). Benign EEG was associated with lower level of NSE compared to malignant and highly malignant patterns (p < 0.001). The NSE level was not significantly increased in patients with seizures as compared with malignant patterns (p = 0.15). In patients with a malignant EEG, a NSE > 45.2 µg/L was predictive of unfavorable outcome with 100% specificity and a higher sensitivity (70.8%) compared to the recommended NSE cut-off of 60 µg/l (Se = 66%). Combined to electrographic seizures, a NSE > 53.5 µg/L predicts poor outcome with 100% specificity and a higher sensitivity (77.7%) compared to the recommended cut-off (Se = 66.6%). Combined to a benign EEG, a NSE level > 78.2 µg/L was highly predictive of a poor outcome with a higher specificity (Sp = 100%) compared to the recommended cut-off (Sp = 94%).

CONCLUSION

In comatose patients after AC, a personalized approach of NSE according to EEG pattern could improve the specificity and sensitivity of this biomarker for poor outcome prediction. Compared to others malignant EEG, no significant difference of NSE level was observed in case of electrographic seizures.

Prognostic Value of Signal Abnormalities on Brain MRI in Post-Anoxic Super-Refractory Status Epilepticus: A Single-Center Retrospective Study

BACKGROUND

Epileptiform activity, including status epilepticus (SE), occurs in up to one-third of comatose survivors of cardiac arrest and may predict poor outcome. The relationship between SE and hypoxic-ischemic brain injury (HIBI) is not established.

METHODS

This is a single-center retrospective study on consecutive patients with post-anoxic super-refractory SE. HIBI was graded as non-widespread (group 1) or widespread (group 2) by qualitative analysis of DWI/ADC and T2w-FLAIR. Between-group differences in the rate of poor neurological outcome at 6 months (primary outcome), SE resolution and consciousness recovery before discharge, and mortality at 6 months (secondary outcomes) were investigated.

RESULTS

From January 2011 to February 2023, 40 patients were included. HIBI was widespread in 45% of patients and non-widespread in 55%. The rate of poor neurological outcome at 6 months was 27% in group 1 and 83% in group 2 (OR 12.8, CI 95% [2.5-64.3], p = 0.002). The rate of consciousness recovery before discharge was 73% in group 1 versus 22% in group 2 (OR 8.8, CI 95% [1.9-40.3], p = 0.005). SE resolved in 95% of patients in group 1 versus 67% in group 2 (OR 10.5, CI 95% [1.1-97.9], p = 0.039). Mortality rate at 6 months was 27% in group 1 versus 50% in group 2 (OR 0.4, CI 95% [0.1-1.9], p = 0.303).

CONCLUSION

Patients with widespread HIBI had higher odds of poor outcome at 6 months, lower probability of SE resolution and of consciousness recovery before discharge compared to those with non-widespread HIBI. Mortality at 6 months did not differ significantly between the two groups.

Evoked potentials in patients with disorders of consciousness

Acute coma in the intensive care unit and persistent disorders of consciousness (DoC) in neuro-rehabilitation are frequent in patients with hypoxic-ischemic encephalopathy after cardiac arrest (CA), traumatic brain injury, intracranial hemorrhage, or ischemic stroke. Reliable prognostication of long-term neurologic outcomes cannot be made by clinical examination alone in the early phase for many patients, and thus, additional investigations are necessary. Evoked potentials provide inexpensive, real-time, high temporal resolution, bedside, quantifiable information on different sensory pathways into the brain including local and global cortical processing. Short-latency somatosensory evoked potentials can reliably predict poor neurologic long-term outcome in the early phase after CA and are recommended by guidelines as one investigation within an early multimodal assessment. Middle-latency and event-related or cognitive evoked potentials provide information on the integrity of more advanced cortical processing, some closely related to consciousness. This information can help to identify those comatose patients with a good prognosis in the acute phase and help to better understand their precise clinical state and the chances of further recovery in patients with persistent DoC in neuro-rehabilitation. Further studies are necessary to improve the applicability of research findings in the clinical sphere.

The Electrographic Effects of Ketamine on Patients With Refractory Status Epilepticus After Cardiac Arrest: A Single-Center Retrospective Cohort

PURPOSE

To investigate the effects of ketamine on patients with refractory status epilepticus after cardiac arrest.

METHODS

In this retrospective cohort, selected EEG segments from patients after cardiac arrest were classified into different EEG patterns (based on background continuity and burden of epileptiform discharges) and spectral profiles (based on the presence of frequency components). For patients who received ketamine, EEG data were compared before, during, and after ketamine infusion; for the no-ketamine group, EEG data were compared at three separated time points during recording. Ketamine usage was determined by clinical providers. Electrographic improvement in epileptiform activity was scored, and the odds ratio was calculated using the Fisher exact test. Functional outcome measures at time of discharge were also examined.

RESULTS

Of a total of 38 patients with postcardiac arrest refractory status epilepticus, 13 received ketamine and 25 did not. All patients were on ≥2 antiseizure medications including at least one sedative infusion (midazolam). For the ketamine group, eight patients had electrographic improvement, compared with only two patients in the no-ketamine group, with an odds ratio of 7.19 (95% confidence interval 1.16-44.65, P value of 0.0341) for ketamine versus no ketamine. Most of the patients who received ketamine had myoclonic status epilepticus, and overall neurologic outcomes were poor with no patients having a favorable outcome.

CONCLUSIONS

For postarrest refractory status epilepticus, ketamine use was associated with electrographic improvement, but with the available data, it is unclear whether ketamine use or EEG improvement can be linked to better functional recovery.

Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians

BACKGROUND

Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown.

OBJECTIVE

To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients.

METHODS

An anonymous electronic survey was distributed to physicians who care for adult postarrest patients.

RESULTS

Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert.

CONCLUSION

Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.

The Evolving Role of Electroencephalography in Postarrest Care

Electroencephalography is an accessible, portable, noninvasive and safe means of evaluating a patient's brain activity. It can aid in diagnosis and management decisions for post-cardiac arrest patients with seizures, myoclonus and other non-epileptic movements. It also plays an important role in a multimodal approach to neuroprognostication predicting both poor and favorable outcomes. Individuals ordering, performing and interpreting these tests, regardless of the indication, should understand the supporting evidence, logistical considerations, limitations and impact the results may have on postarrest patients and their families as outlined herein.

Delayed Deterioration of Electroencephalogram in Patients with Cardiac Arrest: A Cohort Study

BACKGROUND

The aim of this study was to assess the prevalence of delayed deterioration of electroencephalogram (EEG) in patients with cardiac arrest (CA) without early highly malignant patterns and to determine their associations with clinical findings.

METHODS

This was a retrospective study of adult patients with CA admitted to the intensive care unit (ICU) of a university hospital. We included all patients with CA who had a normal voltage EEG, no more than 10% discontinuity, and absence of sporadic epileptic discharges, periodic discharges, or electrographic seizures. Delayed deterioration was classified as the following: (1) epileptic deterioration, defined as the appearance, at least 24 h after CA, of sporadic epileptic discharges, periodic discharges, and status epilepticus; or (2) background deterioration, defined as increasing discontinuity or progressive attenuation of the background at least 24 h after CA. The end points were the incidence of EEG deteriorations and their association with clinical features and ICU mortality.

RESULTS

We enrolled 188 patients in the analysis. The ICU mortality was 46%. Overall, 30 (16%) patients presented with epileptic deterioration and 9 (5%) patients presented with background deterioration; of those, two patients presented both deteriorations. Patients with epileptic deterioration more frequently had an out-of-hospital CA, and higher time to return of spontaneous circulation and less frequently had bystander resuscitation than others. Patients with background deterioration showed a predominantly noncardiac cause, more frequently developed shock, and had multiple organ failure compared with others. Patients with epileptic deterioration presented with a higher ICU mortality (77% vs. 41%; p < 0.01) than others, whereas all patients with background deterioration died in the ICU.

CONCLUSIONS

Delayed EEG deterioration was associated with high mortality rate. Epileptic deterioration was associated with worse characteristics of CA, whereas background deterioration was associated with shock and multiple organ failure.

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care

Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.

EEG Pattern With Spectral Analysis Can Prognosticate Good and Poor Neurologic Outcomes After Cardiac Arrest

PURPOSE

To investigate the prognostic value of a simple stratification system of electroencephalographical (EEG) patterns and spectral types for patients after cardiac arrest.

METHODS

In this prospectively enrolled cohort, using manually selected EEG segments, patients after cardiac arrest were stratified into five independent EEG patterns (based on background continuity and burden of highly epileptiform discharges) and four independent power spectral types (based on the presence of frequency components). The primary outcome is cerebral performance category (CPC) at discharge. Results from multimodal prognostication testing were included for comparison.

RESULTS

Of a total of 72 patients, 6 had CPC 1-2 by discharge, all of whom had mostly continuous EEG background without highly epileptiform activity at day 3. However, for the same EEG background pattern at day 3, 19 patients were discharged at CPC 3 and 15 patients at CPC 4-5. After adding spectral analysis, overall sensitivity for predicting good outcomes (CPC 1-2) was 83.3% (95% confidence interval 35.9% to 99.6%) and specificity was 97.0% (89.5% to 99.6%). In this cohort, standard prognostication testing all yielded 100% specificity but low sensitivity, with imaging being the most sensitive at 54.1% (36.9% to 70.5%).

CONCLUSIONS

Adding spectral analysis to qualitative EEG analysis may further improve the diagnostic accuracy of EEG and may aid developing novel measures linked to good outcomes in postcardiac arrest coma.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Post-hypoxic status epilepticus - A distinct subtype of status epilepticus with poor prognosis

OBJECTIVE

To evaluate the clinical outcome of patients with possible and definitive post-hypoxic status epilepticus (SE) and to describe the SE types in patients with definitive post-hypoxic SE.

METHODS

Patients with definitive or possible SE resulting from hypoxic brain injury after cardiac arrest (CA) were prospectively recruited. Intermittent EEG was used for the diagnosis of SE according to clinical practice. Two raters blinded to outcome analyzed EEGs retrospectively for possible and definitive SE patterns and background features (frequency, continuity, reactivity, and voltage). Definitive SE was classified according to semiology (ILAE). Mortality and Cerebral Performance Categories (CPC) score were evaluated 1 month after CA.

RESULTS

We included 64 patients of whom 92% died. Among the survivors, only one patient had a good neurological outcome (CPC 1). No patient survived with a burst suppression pattern, low voltage, or electro-cerebral silence in any EEG. Possible or definitive SE was diagnosed in a median of 47 h (IQR 39-72 h) after CA. EEG criteria for definitive electrographic SE were fulfilled in 39% of patients; in 38% - for electroclinical SE and in 23% - for ictal-interictal continuum (IIC). The outcome did not differ significantly between the three groups. The only patient with good functional outcome belonged to the IIC group. Comatose non-convulsive SE (NCSE) without subtle motor phenomenon occurred in 20% of patients with definitive electrographic SE and outcome was similar to other types of SE.

SIGNIFICANCE

Possible or definitive SE due to hypoxic brain injury is associated with poor prognosis. The outcome of patients with electrographic SE, electroclinical SE, and IIC did not differ significantly. Outcome was similar in patients with definitive electrographic SE with and without prominent motor features.

Neurologic Complications of Critical Medical Illness

OBJECTIVE

This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients.

LATEST DEVELOPMENTS

Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities.

ESSENTIAL POINTS

Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.

Cognition, emotional state, and quality of life of survivors after cardiac arrest with rhythmic and periodic EEG patterns

AIM

Rhythmic and periodic patterns (RPPs) on the electroencephalogram (EEG) in comatose patients after cardiac arrest have been associated with high case fatality rates. A good neurological outcome according to the Cerebral Performance Categories (CPC) has been reported in up to 10% of cases. Data on cognitive, emotional, and quality of life outcomes are lacking. We aimed to provide insight into these outcomes at one-year follow-up.

METHODS

We assessed outcome of surviving comatose patients after cardiac arrest with RPPs included in the 'treatment of electroencephalographic status epilepticus after cardiopulmonary resuscitation' (TELSTAR) trial at one-year follow-up, including the CPC for functional neurological outcome, a cognitive assessment, the hospital anxiety and depression scale (HADS) for emotional outcomes, and the 36-item short-form health survey (SF-36) for quality of life. Cognitive impairment was defined as a score of more than 1.5 SD below the mean on ≥ 2 (sub)tests within a cognitive domain.

RESULTS

Fourteen patients were included (median age 58 years, 21% female), of whom 13 had a cognitive impairment. Eleven of 14 were impaired in memory, 9/14 in executive functioning, and 7/14 in attention. The median scores on the HADS and SF-36 were all worse than expected. Based on the CPC alone, 8/14 had a good outcome (CPC 1-2).

CONCLUSION

Nearly all cardiac arrest survivors with RPPs during the comatose state have cognitive impairments at one-year follow-up. The incidence of anxiety and depression symptoms seem relatively high and quality of life relatively poor, despite 'good' outcomes according to the CPC.

Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement

Cardiac arrest (CA) is associated with a low rate of survival with favourable neurologic recovery. The most common mechanism of death after successful resuscitation from CA is withdrawal of life-sustaining measures on the basis of perceived poor neurologic prognosis due to underlying hypoxic-ischemic brain injury. Neuroprognostication is an important component of the care pathway for CA patients admitted to hospital but is complex, challenging, and often guided by limited evidence. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the evidence underlying factors or diagnostic modalities available to determine prognosis, recommendations were generated in the following domains: (1) circumstances immediately after CA; (2) focused neurologic exam; (3) myoclonus and seizures; (4) serum biomarkers; (5) neuroimaging; (6) neurophysiologic testing; and (7) multimodal neuroprognostication. This position statement aims to serve as a practical guide to enhance in-hospital care of CA patients and emphasizes the adoption of a systematic, multimodal approach to neuroprognostication. It also highlights evidence gaps.

Epileptiform patterns predicting unfavorable outcome in postanoxic patients: A matter of time?

OBJECTIVE

Historically, epileptiform malignant EEG patterns (EMPs) have been considered to anticipate an unfavorable outcome, but an increasing amount of evidence suggests that they are not always or invariably associated with poor prognosis. We evaluated the prognostic significance of an EMP onset in two different timeframes in comatose patients after cardiac arrest (CA): early-EMPs and late-EMPs, respectively.

METHODS

We included all comatose post-CA survivors admitted to our intensive care unit (ICU) between 2016 and 2018 who underwent at least two 30-minute EEGs, collected at T0 (12-36 h after CA) and T1 (36-72 h after CA). All EEGs recordings were re-analyzed following the 2021 ACNS terminology by two senior EEG specialists, blinded to outcome. Malignant EEGs with abundant sporadic spikes/sharp waves, rhythmic and periodic patterns, or electrographic seizure/status epilepticus, were included in the EMP definition. The primary outcome was the cerebral performance category (CPC) score at 6 months, dichotomized as good (CPC 1-2) or poor (CPC 3-5) outcome.

RESULTS

A total of 58 patients and 116 EEG recording were included in the study. Poor outcome was seen in 28 (48%) patients. In contrast to late-EMPs, early-EMPs were associated with a poor outcome (p = 0.037), persisting after multiple regression analysis. Moreover, a multivariate binomial model coupling the timing of EMP onset with other EEG predictors such as T1 reactivity and T1 normal voltage background can predict outcome in the presence of an otherwise non-specific malignant EEG pattern with quite high specificity (82%) and moderate sensitivity (77%).

CONCLUSIONS

The prognostic significance of EMPs seems strongly time-dependent and only their early-onset may be associated with an unfavorable outcome. The time of onset of EMP combined with other EEG features could aid in defining prognosis in patients with intermediate EEG patterns.

Prognostication after cardiac arrest: how EEG and evoked potentials may improve the challenge

About 80% of patients resuscitated from CA are comatose at ICU admission and nearly 50% of survivors are still unawake at 72 h. Predicting neurological outcome of these patients is important to provide correct information to patient's relatives, avoid disproportionate care in patients with irreversible hypoxic-ischemic brain injury (HIBI) and inappropriate withdrawal of care in patients with a possible favorable neurological recovery. ERC/ESICM 2021 algorithm allows a classification as "poor outcome likely" in 32%, the outcome remaining "indeterminate" in 68%. The crucial question is to know how we could improve the assessment of both unfavorable but also favorable outcome prediction. Neurophysiological tests, i.e., electroencephalography (EEG) and evoked-potentials (EPs) are a non-invasive bedside investigations. The EEG is the record of brain electrical fields, characterized by a high temporal resolution but a low spatial resolution. EEG is largely available, and represented the most widely tool use in recent survey examining current neuro-prognostication practices. The severity of HIBI is correlated with the predominant frequency and background continuity of EEG leading to "highly malignant" patterns as suppression or burst suppression in the most severe HIBI. EPs differ from EEG signals as they are stimulus induced and represent the summated activities of large populations of neurons firing in synchrony, requiring the average of numerous stimulations. Different EPs (i.e., somato sensory EPs (SSEPs), brainstem auditory EPs (BAEPs), middle latency auditory EPs (MLAEPs) and long latency event-related potentials (ERPs) with mismatch negativity (MMN) and P300 responses) can be assessed in ICU, with different brain generators and prognostic values. In the present review, we summarize EEG and EPs signal generators, recording modalities, interpretation and prognostic values of these different neurophysiological tools. Finally, we assess the perspective for futures neurophysiological investigations, aiming to reduce prognostic uncertainty in comatose and disorders of consciousness (DoC) patients after CA.

Electroencephalogram in the intensive care unit: a focused look at acute brain injury

Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.

Continuous versus routine EEG in patients after cardiac arrest-Analysis of a randomized controlled trial (CERTA) - RESUS-D-22-00369

BACKGROUND

Electroencephalography (EEG) is essential to assess prognosis in patients after cardiac arrest (CA). Use of continuous EEG (cEEG) is increasing in critically-ill patients, but it is more resource-consuming than routine EEG (rEEG). Observational studies did not show a major impact of cEEG versus rEEG on outcome, but randomized studies are lacking.

METHODS

We analyzed data of the CERTA trial (NCT03129438), including comatose adults after CA undergoing cEEG (30-48 hours) or two rEEG (20-30 minutes each). We explored correlations between recording EEG type and mortality (primary outcome), or Cerebral Performance Categories (CPC, secondary outcome), assessed blindly at 6 months, using uni- and multivariable analyses (adjusting for other prognostic variables showing some imbalance across groups).

RESULTS

We analyzed 112 adults (52 underwent rEEG, 60 cEEG,); 31 (27.7%) were women; 68 (60.7%) patients died. In univariate analysis, mortality (rEEG 59%, cEEG 65%, p=0.318) and good outcome (CPC 1-2; rEEG 33%, cEEG 27%, p=0.247) were comparable across EEG groups. This did not change after multiple logistic regressions, adjusting for shockable rhythm, time to return of spontaneous circulation, serum neuron-specific enolase, EEG background reactivity, regarding mortality (rEEG vs cEEG: OR 1.60, 95% CI 0.43 - 5.83, p=0.477), and good outcome (OR 0.51, 95% CI 0.14 - 1.90, p=0.318).

CONCLUSION

This analysis suggests that cEEG or repeated rEEG are related to comparable outcomes of comatose patients after CA. Pending a prospective, large randomized trial, this finding does not support the routine use of cEEG for prognostication in this setting. Trial registration Continuous EEG Randomized Trial in Adults (CERTA); NCT03129438; July 25, 2019.

Revisiting EEG as part of the multidisciplinary approach to post-cardiac arrest care and prognostication: A review

Since the 1960s, EEG has been used to assess the neurologic function of patients in the hours and days after cardiac arrest. Accurate and reliable prognostication after cardiac arrest is vital for tailoring aggressive patient care for those with a high likelihood of recovery and setting appropriate goals of care for those who have a high likelihood of a poor outcome. Attempts to define EEG's role in this process has evolved over the years. In this review, we provide important historical context about EEG's use, it's perceived unreliability in the post-cardiac arrest patient in the past and provide a detailed analysis of how this role has changed recently. A review of the 71 most recent and highest quality studies demonstrates that the introduction of a uniform classification and a timed approach to EEG analysis have positioned EEG as a complementary tool in the multimodal approach for prognostication. The review was created and intended for medical staff in the intensive care units and emphasizes EEG patterns and timing which portend both favorable and poor prognoses. Also, the review addresses the overall quality of the existing studies and discusses future directions to address the knowledge gaps in this field.

Treating Rhythmic and Periodic EEG Patterns in Comatose Survivors of Cardiac Arrest

BACKGROUND

Whether the treatment of rhythmic and periodic electroencephalographic (EEG) patterns in comatose survivors of cardiac arrest improves outcomes is uncertain.

METHODS

We conducted an open-label trial of suppressing rhythmic and periodic EEG patterns detected on continuous EEG monitoring in comatose survivors of cardiac arrest. Patients were randomly assigned in a 1:1 ratio to a stepwise strategy of antiseizure medications to suppress this activity for at least 48 consecutive hours plus standard care (antiseizure-treatment group) or to standard care alone (control group); standard care included targeted temperature management in both groups. The primary outcome was neurologic outcome according to the score on the Cerebral Performance Category (CPC) scale at 3 months, dichotomized as a good outcome (CPC score indicating no, mild, or moderate disability) or a poor outcome (CPC score indicating severe disability, coma, or death). Secondary outcomes were mortality, length of stay in the intensive care unit (ICU), and duration of mechanical ventilation.

RESULTS

We enrolled 172 patients, with 88 assigned to the antiseizure-treatment group and 84 to the control group. Rhythmic or periodic EEG activity was detected a median of 35 hours after cardiac arrest; 98 of 157 patients (62%) with available data had myoclonus. Complete suppression of rhythmic and periodic EEG activity for 48 consecutive hours occurred in 49 of 88 patients (56%) in the antiseizure-treatment group and in 2 of 83 patients (2%) in the control group. At 3 months, 79 of 88 patients (90%) in the antiseizure-treatment group and 77 of 84 patients (92%) in the control group had a poor outcome (difference, 2 percentage points; 95% confidence interval, -7 to 11; P = 0.68). Mortality at 3 months was 80% in the antiseizure-treatment group and 82% in the control group. The mean length of stay in the ICU and mean duration of mechanical ventilation were slightly longer in the antiseizure-treatment group than in the control group.

CONCLUSIONS

In comatose survivors of cardiac arrest, the incidence of a poor neurologic outcome at 3 months did not differ significantly between a strategy of suppressing rhythmic and periodic EEG activity with the use of antiseizure medication for at least 48 hours plus standard care and standard care alone. (Funded by the Dutch Epilepsy Foundation; TELSTAR ClinicalTrials.gov number, NCT02056236.).

Critical care EEG standardized nomenclature in clinical practice: Strengths, limitations, and outlook on the example of prognostication after cardiac arrest

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Optimal use of the ACNS nomenclature implies integration of clinical information.

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Knowledge of pathophysiological mechanisms of EEG patterns may help interpretation.

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Standardized therapeutic procedures for critical care patients are needed.

We discuss the achievements of the ACNS critical care EEG nomenclature proposed in 2013 and, from a clinical angle, outline some limitations regarding translation into treatment implications. While the recently proposed updated 2021 version of the nomenclature will probable improve some uncertainty areas, a refined understanding of the mechanisms at the origin of the EEG patterns, and a multimodal integration of the nomenclature to the clinical context may help improving the rationale supporting therapeutic procedures. We illustrate these aspects on prognostication after cardiac arrest.

Early vigabatrin augmenting GABA-ergic pathways in post-anoxic status epilepticus (VIGAB-STAT) phase IIa clinical trial study protocol

Background

Nearly one in three unconscious cardiac arrest survivors experience post-anoxic status epilepticus (PASE). Historically, PASE has been deemed untreatable resulting in its exclusion from status epilepticus clinical trials. However, emerging reports of survivors achieving functional independence following early and aggressive treatment of PASE challenged this widespread therapeutic nihilism. In the absence of proven therapies specific to PASE, standard of care treatment leans on general management strategies for status epilepticus. Vigabatrin—an approved therapy for refractory focal-onset seizures in adults—inhibits the enzyme responsible for GABA catabolism, increases brain GABA levels and may act synergistically with anesthetic agents to abort seizures. Our central hypothesis is that early inhibition of GABA breakdown is possible in the post-cardiac arrest period and may be an effective adjunctive treatment in PASE.

Methods

This is a phase IIa, single-center, open-label, pilot clinical trial with blinded outcome assessment, of a single dose of vigabatrin in 12 consecutive PASE subjects. Subjects will receive a single loading dose of 4500 mg of vigabatrin (or dose adjusted in moderate and severe renal impairment) via enteric tube within 48 h of PASE onset. Vigabatrin levels will be monitored at 0- (baseline), 0.5-, 1-, 2-, 3-, 6-, 12-, 24-, 48-, 72- and 168-h (7 days) post-vigabatrin. Serum biomarkers of neuronal injury will be measured at 0-, 24-, 48-, 72- and 96-h post-vigabatrin. The primary feasibility endpoint is the proportion of enrolled subjects among identified eligible subjects receiving vigabatrin within 48 h of PASE onset. The primary pharmacokinetic endpoint is the measured vigabatrin level at 3 h post-administration. Descriptive statistics with rates and proportions will be obtained regarding feasibility outcomes, along with the noncompartmental method for pharmacokinetic analyses. The area under the vigabatrin concentration-time curve in plasma from zero to the time of the last quantifiable concentration (AUC0-tlqc) will be calculated to estimate dose-linear pharmacokinetics.

Perspective

Vigabatrin demonstrates high potential for synergism with current standard of care therapies. Demonstration of the feasibility of vigabatrin administration and preliminary safety in PASE will pave the way for future efficacy and safety trials of this pharmacotherapeutic.

Trial Registration NCT04772547.

Early Neuroprognostication Using Frontal Spectrograms in Moderately Sedated Cardiac Arrest Patients

Introduction. The integrated suppression ratio throughout all electroencephalography (EEG) patterns has rarely been studied. The aim of this study was to evaluate the clinical utility of the suppression ratio and hyperactivity of EEG on spectrograms. Methods. This prospective observational study included 73 cardiac arrest patients. Hardwired frontal EEG monitoring with spectrograms (color density spectral arrays, CDSA) was used to predict neurological outcomes. The mean suppression ratio (MSR) and hyperactivity in the high-frequency band (HHF) in the spectrogram were investigated in moderately sedated patients. Sedative doses were considered to estimate the MSR, which was automatically measured. Results. Using propofol 30 to 40 µg/kg/min and remifentanil 0.1 to 0.15 µg/kg/min, all the patients with an MSR >30% died. At day 2, the MSR in patients with a good outcome was 0%. The cut off values were different as an MSR >30% at day 1 (AUC 0.815) and an MSR >1% at day 2 (AUC 0.891). Of the patients with an MSR ≤30%, HHF was the greatest predictor of a poor outcome (OR 12.858, P = .006). The best predictors of a poor outcome using the spectrogram were suppression ratio (SR) >30% or HHF at day 1 (AUC 0.88) and SR >1% or HHF at day 2 (AUC 0.909). Conclusions. The use of MSR and HHF in frontal spectrograms is convenient and may be successfully employed for early neuroprognostication in moderately sedated cardiac arrest patients. However, spectrograms should be used with electroencephalogram considering the effects of sedatives because of the imperfect detection of electrographic seizures and artifacts.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

Continuous EEG monitoring in the follow-up of convulsive status epilepticus patients: A proposal and preliminary validation of an EEG-based seizure build-up score (EaSiBUSSEs)

Continuous electroencephalography (EEG) is a major tool for monitoring patients admitted to the intensive care unit after refractory convulsive status epilepticus, following control of convulsive movements. We review the values of different EEG patterns observed in critically ill patients for prognosis and seizure risk, together with proposed criteria for non-convulsive status epilepticus diagnosis (Salzburg Criteria), the EEG scores for prognosis (Epidemiology-based Mortality score in Status Epilepticus, EMSE) and for seizure risk (2HELPS2B). These criteria and scores, based partially on continuous EEG, are not tailored to repetitively monitor the progressive build-up leading to seizure or status epilepticus recurrence. Therefore, we propose a new EEG-based seizure build-up score in status epilepticus (EaSiBUSSEs), based on the morphology and the prevalence of the EEG patterns observed in the follow-up of convulsive status epilepticus patients. It displays subscores from the least (no interictal activity) to the most associated with seizures (focal or generalized status epilepticus). We then evaluated the performance of the EaSiBUSSEs in a cohort of eleven patients who were admitted to intensive care unit for convulsive status epilepticus and who underwent continuous EEG recording. The receiver operating curve revealed good accuracy in identifying patients who would have seizures in the next 24 h, with excellent intra- and inter-rater reliability. We believe that this score is simple to perform, and suitable for repeated monitoring of EEG following refractory convulsive status epilepticus, with quantitative description of major EEG changes leading to seizures.

Update on the management of status epilepticus

PURPOSE OF REVIEW

Randomized controlled trials investigating the initial pharmacological treatment of status epilepticus have been recently published. Furthermore, status epilepticus arising in comatose survivors after cardiac arrest has received increasing attention in the last years. This review offers an updated assessment of status epilepticus treatment in these different scenarios.

RECENT FINDINGS

Initial benzodiazepines underdosing is common and correlates with development of status epilepticus refractoriness. The recently published ESETT trial provides high-level evidence regarding the equivalence of fosphenytoin, valproate, and levetiracetam as a second-line option. Myoclonus or epileptiform transients on electroencephalography occur in up to 1/3 of patients surviving a cardiac arrest. Contrary to previous assumptions regarding an almost invariable association with death, at least 1/10 of them may awaken with reasonably good prognosis, if treated. Multimodal prognostication including clinical examination, EEG, somatosensory evoked potentials, biochemical markers, and neuroimaging help identifying patients with a chance to recover consciousness, in whom a trial with antimyoclonic compounds and at times general anesthetics is indicated.

SUMMARY

There is a continuous, albeit relatively slow progress in knowledge regarding different aspect of status epilepticus; recent findings refine some treatment strategies and help improving patients' outcomes. Further high-quality studies are clearly needed to further improve the management of these patients, especially those with severe, refractory status epilepticus forms.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation

More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.

Status epilepticus - time is brain and treatment considerations

PURPOSE OF REVIEW

Status epilepticus is a neurological emergency associated with high morbidity and mortality. There is a lack of robust data to guide the management of this neurological emergency beyond the initial treatment. This review examines recent literature on treatment considerations including the choice of continuous anesthetics or adjunctive anticonvulsant, the cause of the status epilepticus, and use of nonpharmacologic therapies.

RECENT FINDINGS

Status epilepticus remains undertreated and mortality persists to be unchanged over the past 30 years. New anticonvulsant choices, such as levetiracetam and lacosamide have been explored as alternative emergent therapies. Anecdotal reports on the use of other generation anticonvulsants and nonpharmacologic therapies for the treatment of refractory and super-refractory status epilepticus have been described.Finally, recent evidence has examined etiology-guided management of status epilepticus in certain patient populations, such as immune-mediated, paraneoplastic or infectious encephalitis and anoxic brain injury.

SUMMARY

Randomized clinical trials are needed to determine the role for newer generation anticonvulsants and nonpharmacologic modalities for the treatment of epilepticus remains and evaluate the long-term outcomes associated with continuous anesthetics.