Seizures and Cognitive Outcome After Traumatic Brain Injury: A Post Hoc Analysis

INTRODUCTION

Seizures and abnormal periodic or rhythmic patterns are observed on continuous electroencephalography monitoring (cEEG) in up to half of patients hospitalized with moderate to severe traumatic brain injury (TBI). We aimed to determine the impact of seizures and abnormal periodic or rhythmic patterns on cognitive outcome 3 months following moderate to severe TBI.

METHODS

This was a post hoc analysis of the multicenter randomized controlled phase 2 INTREPID²⁵⁶⁶ clinical trial conducted from 2010 to 2016 across 20 United States Level I trauma centers. Patients with nonpenetrating TBI and postresuscitation Glasgow Coma Scale scores 4-12 were included. Bedside cEEG was initiated per protocol on admission to intensive care, and the burden of ictal-interictal continuum (IIC) patterns, including seizures, was quantified. A summary global cognition score at 3 months following injury was used as the primary outcome.

RESULTS

142 patients (age mean + / - standard deviation 32 + / - 13 years; 131 [92%] men) survived with a mean global cognition score of 81 + / - 15; nearly one third were considered to have poor functional outcome. 89 of 142 (63%) patients underwent cEEG, of whom 13 of 89 (15%) had severe IIC patterns. The quantitative burden of IIC patterns correlated inversely with the global cognition score (r =  - 0.57; p = 0.04). In multiple variable analysis, the log-transformed burden of severe IIC patterns was independently associated with the global cognition score after controlling for demographics, premorbid estimated intelligence, injury severity, sedatives, and antiepileptic drugs (odds ratio 0.73, 95% confidence interval 0.60-0.88; p = 0.002).

CONCLUSIONS

The burden of seizures and abnormal periodic or rhythmic patterns was independently associated with worse cognition at 3 months following TBI. Their impact on longer-term cognitive endpoints and the potential benefits of seizure detection and treatment in this population warrant prospective study.

Status Epilepticus: Work-Up and Management in Adults

Status epilepticus is one of the most common neurological emergencies and is likely to have increasing prevalence in coming years given an aging "baby boomer" population in the United States. Because status epilepticus is associated with significant morbidity and mortality, identification and treatment are paramount. Care should be taken to exclude nonorganic mimics and infectious and metabolic causes. Status epilepticus can be classified into stages with associated recommendations for escalation in therapy, increasing from push-dose benzodiazepines to continuous anesthetic infusions and other nontraditional therapies. Concurrent electroencephalogram monitoring helps to identify, localize, and assess resolution of ictal patterns alongside antiseizure drug administration. A protocol is proposed for the management of status epilepticus in a step-wise fashion.

Abstract W P127: Epidemiology of Cerebrovascular Disease: Association Between Geographic Location and In-Hospital Mortality

Background: Extant literature suggests that the South has the lowest ground and air access to Neurocritical Care Units (NCUs) and has the highest number of admissions for subarachnoid hemorrhages (SAH) and intracerebral hemorrhages (ICH) than in other regions. NCUs have been shown to improve outcomes for patients with SAH and ICH, and delayed access may be potentially harmful. Evaluating for in-hospital mortality after SAH or ICH in regions with less access to NCUs may prove useful in determining the need for adequate access.

Objectives: We sought to determine the in-hospital mortality trends for SAH and ICH from 1979 to 2008 per geographic region in relation to the US 2000 standard death rate to derive adjusted comparisons.

Methods: The sample was obtained from the National Hospital Discharge Survey (NHDS) and cases were identified using the ICD-9-CM codes 430 for SAH and 431 for ICH. Age and geographic regions were divided into subgroups according to NHDS recommendations. Annual data was divided into 6 epochs for analysis of temporal changes.

Results: We identified 612,600 cases of SAH and 1,530,613 cases of ICH in the US over a 30-year study period. Overall, crude in-hospital mortality after SAH or ICH was highest in the South [32% (95% CI, 29-35%) and 34% (95% CI, 32-35%), respectively] ( p = 0.001). Crude in-hospital mortality after SAH and ICH per epoch demonstrated a positive temporal trend supported by the Cochran-Armitage trend test (p < 0.0001) and was highest in the South during the sixth epoch (2004-2008) at 24% (95% CI, 22-26%) ( p = 0.001). After adjusting to the US 2000 standard death rate, there was excess mortality in the South with a standard mortality ratio of 1.25 (99% CI, 1.24-1.26) ( p < 0.01) as compared to other regions except for in the Northeast, which was an unanticipated finding.

Conclusions: In-hospital mortality specific to SAH and ICH is higher in US regions identifiable with less access to NCUs when adjusted for all-cause mortality in the US. This study raises numerous questions regarding impact of NCU access and highlights the need for additional data and efforts to maximize access in an efficient manner.