pediatric continuous eeg monitoring: case...

Pediatric Continuous EEG Monitoring:

Case PresentationDecember 5, 2011

Sudha Kilaru Kessler M.D.

Assistant Professor of Neurology and Pediatrics

Children’s Hospital of Philadelphia

University of Pennsylvania

American Epilepsy Society | Annual Meeting

Disclosure

No disclosures


Learning Objectives

This case provides a framework for considering how continuous EEG monitoring is used in the

pediatric intensive care setting.


Introduction

• 9 year old previously healthy girl.

• Presented to the emergency department after 3

days of headache, nausea, emesis.

• Examination: right hemianopsia.

• Increasingly somnolent within hours.

• Head CT, toxicology screen, blood count, basic

metabolic panel were all unrevealing.

• Admitted to the pediatric intensive care unit.

• Is an EEG needed? EEG monitoring?

American Epilepsy Society Annual Meeting

Non-Convulsive Seizures:

Prevalence, Risk Factors and

Indications for EEG Monitoring

December 5, 2011

Nicholas Abend, MDAssistant Professor of Neurology & Pediatrics

The Children’s Hospital of Philadelphia &

University of Pennsylvania School of Medicine


Disclosure

None.


Learning Objectives

• List current indications for EEG

monitoring in critically ill children.

• Discuss the incidence of non-convulsive

seizures in critically ill children.

• Identify children at increased risk for

non-convulsive seizures.

• Select how long to monitor children.


Seizures are the most common pediatric

neuro-ICU conditions leading to neurologic

consultation (35%).Bell MJ, Carpenter J, Au AK, Keating RF, Myseros JS, Yaun A, Weinstein S. Neurocritical Care, 2008

6-7% of PICU patients undergo

continuous EEG (cEEG) monitoring.2007-2008 Melbourne Shahwan A, Bailey C, Shekerdemian L, Harvey AS. Epilepsia, 2010.

2010 Philadelphia Abend NS, unpublished

De Georgia MA, Deogaonkar A. Neurologist , 2005

EEG

DISADVANTAGES

Technical expertise.

Interpretation expertise.

Findings often non-specific.

Expensive.

ADVANTAGES

Non-invasive.

Extensive coverage.

Available at bedside.

Continuous data acquisition.

Functional test.

1. Current Practice - cEEG & NCS Management

2. Impact of cEEG on Management

3. Non-Convulsive Seizure Epidemiology

“Yes, I’d like to ask a very specific question that pertains

to only me, and then go on and on and on…”

Responses from 47/50 US and 11/11 Canadian institutions. US News & World Report - 50 neurology/neurosurgery programs.

1 response per institution.

31 questions (5-10 minutes).

Significant increase (~30%) in patients undergoing cEEG over 1 year. United States - median of 10 patients per month.

Canada – median 3 patients per month.

Sanchez S, Carpenter J, Chapman KE, Dlugos DJ, Giza CC, Hahn CD, Kessler SK, Goldstein J, Loddenkemper T, Riviello JJ,

Abend NS. For the Pediatric Critical Care EEG Consortium (PCCEG).

cEEG Indication %

Event Characterization (movement, Δvital signs) 95%

ΔMS after seizure or status epilepticus 97%

ΔMS with acute primary neurologic disorder 88%

ΔMS of unknown etiology 88%

ΔMS & systemic disorder (no neurologic disorder) 72%

Resuscitation from Cardiac Arrest 62%

Traumatic Brain Injury 53%

Extra Corporal Membrane Oxygenation (ECMO) 34%

EEG Review Frequency %

Technologist Review

Never 27%

1 per day 16%

2 per day 27%

3 per day 4%

4 per day 5%

>4 per day 7%

Continuously 14%

Physician Review

1 per day 19%

2 per day 37%

3 per day 19%

4 per day 7%

>4 per day 17%

Continuously 2%

Technologists:

Available 24/7: 79% (51% by call-back)

Screen EEG: 50%.

330 physicians responded.

Academic/Tertiary Care 85%

cEEG Available 24/7 80%

cEEG > 1 patient per month 83%

Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care 2010.

79

125

0.56

26

63

3 10

25

50

75

100

An

y N

CS

Mu

ltip

le N

CS

On

ly N

CS

E

Ne

ve

r

To

lera

te <

10

N

CS

per

day

To

lera

te <

5

NC

S p

er

day

Te

rmin

ate

all

NC

S

Ind

uce

Bu

rst

Suppre

ssio

n

Ind

uce

E

lectr

oce

reb

ral

Sile

nce

% o

f R

es

po

nd

en

ts

Treatment Initiation Overall Treatment Goal

40

20

28

3 2 40

10

20

30

40

50

% o

f R

es

po

nd

en

ts

Anticonvulsant for NCS

32

9

44

72 4

0

10

20

30

40

50

% o

f R

es

po

nd

en

ts

Anticonvulsant for NCSE

4

19

56

21

5

29

60

6

0

25

50

75

100

Persist after 1st

AED

Persist after 2nd

AED

Persist after 3rd

AED

Never if only NCS

Persist after 1st

AED

Persist after 2nd

AED

Persist after 3rd

AED

Never if only

NCSE

Coma Induction for NCS Coma Induction for NCSE

% o

f R

es

po

nd

en

ts

NCS NCSE

cEEG to screen for NCS in children with:

Δ MS of unknown etiology,

Δ MS and a known acute neurologic disorder.

Δ MS following a convulsion.

Screening twice per day is most common practice.

Clinical uncertainty: overall NCS management

approach and specific AED choices.

Evidence-based pathways are needed.

Sanchez S, Carpenter J, Chapman KE, Dlugos DJ, Giza CC, Hahn CD, Kessler SK, Goldstein J, Loddenkemper T, Riviello JJ,

Abend NS. For the Pediatric Critical Care EEG Consortium (PCCEG).


“Off hand, I’d say you’re suffering from an arrow

through your head, but just to play it safe, I’m ordering

a bunch of tests.”

N=100, Prospective consecutive, Tertiary care PICU.

cEEG if acute neurologic disorder with ΔMS.

Median Age = 2.9 years

Median cEEG Duration = 2 days

Acute Encephalopathy Etiology: HIE 31 Epilepsy 24 CNS Infection 10 Other Non-Structural 10

TBI 7 Stroke 7 Other Structural 6 Neurosurgical 5

cEEG impact: Δ AED, Event not sz, Urgent imaging.Abend NS, Topjian AA, Gutierrez-Colina AM, Donnelly M, Clancy RR, Dlugos DJ. Neurocritical Care. 2011.

• cEEG impacted management in 60 of 100.

• Urgent Neuroimaging = 5 (3 impacted management)

• NCS identified = 39

• Paroxysmal Event Not Seizure = 21

Movement = 16 (4 had unrelated NCS)

Vital sign fluctuation = 5 (3 had unrelated NCS)

• Total of 46 had NCS

• AED changes = 47

Initiate=28 Escalate = 15 Discontinue = 4

Critically ill children: Retrospective, N=122

Seizures = 38%

Non-Epileptic Events = 27%▪ apnea, desats, ICP increases, tachycardia, abn movements.

Williams K, Jarrar R, Buchhalter J. Epilepsia, 2011.

Critically Ill adults: Retrospective, N=300

cEEG led to AED changes in 52% (Initiation 14%, Modification 33%, Discontinuation 5%)

Kilbride RD, Costello DJ, Chiappa KH. Arch Neuro. 2009.

NCS-NCSE in 7-100% of critically ill children.

Age

Etiology of Acute Neurologic Disorder

cEEG Indication

Study Design

StudyConvulsive

SETBI ICH SAH

Altered

Mental Status

Medical

ICU

Claassen 2004 20% 8% 9% 13% 5%

DeLorenzo 1998 14%

Trieman 1998 32%

Vespa 2010 23%

Vespa 2003 11%

Claassen 2007 7%

Alroughani 2008 9%

Towne 2000 8%

Kilbride 2009 28%

Oddo 2009 10%

McHugh 2009 2%

Study EpilepsyΔ

MSHIE TBI Tumor ICH Stroke

CNS

Infxn

Toxic-

Metab

Alehan

2001 29% 14%

Hosain

2005 33%

Jette

2006 71% 72% 54% 57% 66% 100% 66% 100% 55%

Saengpattrachai

2006 16%

Hyllienmark

2007 17%

Abend

2009 48%

Shahwan

2010 7%

Abend

2011 46% 39% 29% 40% 71% 70% 40%

Williams

2011 52% 21% 70% 33%

McCoy

2011 50% 40% 14%

StudyN

AgeEEG Indication

% with

Acute

CNS

Disorder

NCS

or

NCSE

Abend

2009

19

Peds/p Cardiac Arrest with HIE 100% 48%

Abend

2011

100

PedΔMS & acute CNS condition 100% 46%

Jette

2006

117

Neo+Ped

Critically ill and underwent

cEEG >68% 39%

Williams

2011

122

Neo+Ped


cEEG >62% 38%

McCoy

2011

121

Neo+Ped


cEEG 52% 29%

Shahwan

2010

100

Ped

Sustained depressed

consciousness 50% 7%

StudyN

LocationEEG Indication

Study

Type

NCS

or

NCSE

Abend 2011100

Ped

ΔMS & acute CNS

conditionPro 46%

Jette 2006117

Neo+Ped

Critically ill and

underwent cEEGRetro 39%

Williams 2011122

Neo+Ped

Critically ill and


Hosain 2005178

Neo+Ped

Persistently

unresponsiveRetro 33%

McCoy 2011121

Neo+Ped

Critically ill and


Saengpattrachai

2006

141

Ped

Unexplained ΔMS and

underwent EEGRetro 16%

100 critically ill children

Seizures

46

Non-Convulsive Seizures

27

Non-Convulsive Only

20

Non-Convulsive & Convulsive

7

Non-Convulsive

Status Epilepticus

19

Non-Convulsive Only

12

Non-Convulsive & Convulsive

7No Seizures

54

cEEG Indication:

acute neurologic

disorder with ΔMS

Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R,

Donnelly M, Clancy RR, Dlugos DJ. Neurology. 2011.

NCS Only: 29-75% of those with seizures. Jette N. et al., 2005 ; Abend NS et al., 2011; Williams K. et al., 2011 ; Shahwan A, et al. 2010; McCoy B et al., 2011.

Many seizures would be missed without cEEG,

even with optimal clinical observation.

6% receiving paralytics while NCS occurred.Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M, Clancy RR, Dlugos DJ. Neurology. 2011.

Electromechanical uncoupling/dissociation.

Clinical Risk Factors:

Younger Age Abend et al., 2011; Williams et al., 2011

Convulsive SE Williams et al.,2011

Acute Seizures McCoy et al., 2011

Acute Structural Brain Injury McCoy et al., 2011

TBI Williams et al., 2011

Electrographic Risk Factors:

Lack of Reactivity Jette et al., 2006

Epileptiform Discharges Williams et al. 2011; Jette et al., 2006; McCoy et al., 2011

Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M,

Clancy RR, Dlugos DJ. Neurology. 2011.

80-100% of

NCS

detected

within 24

hours.Hyllienmark, L. et al., 2005

Jette N et al., 2006

Shahwan A et al., 2010

Williams K et al., 2011

McCoy B et al., 2011

13%

Identifying the remaining 13% would require a

tripling of cEEG monitoring days.

16

10

4 3

47

17

3

28

64 5

48

7

2

8

42 2

40

29

15

0

10

20

30

40

50

1 Hr 3 Hrs 6 Hrs 12 Hrs 24 Hrs 48 Hrs 72 Hrs

% o

fR

esp

on

den

ts

Hours of cEEG if No Seizures Detected

Comatose Obtunded/Lethargic PEDs Present


Observational, N=200, NCS-NCSE=82, AEDs=80.

Topjian AA, Sanchez S, Berg RA, Dlugos DJ, Abend NS. In preparation.

74

21

3

36

0

25

50

75

100

Electrographic Seizures

Electrographic Status Epilepticus

%

1st Anticonvulsant Effective Refractory (≥4 anticonvulsants)

Topjian AA, Sanchez S, Berg RA, Dlugos DJ, Abend NS. In preparation.

*No difference (p=0.39) after controlling for age and acute neurologic disorder.

0

25

50

75

100

PH

T-F

OS

PB

LE

V

VP

A

PH

T-F

OS

PB

LE

V

VP

A

Initial AC Administered Initial AC Efficacy

%

ES ESE

PHT- PB LEV VPA PHT- PB LEV VPA

FOS FOS

Initial Anticonvulsant Initial Anticonvulsant

Administered Efficacy*

1. Current Practice - cEEG & NCS Management cEEG increasingly used to identify NCS in at-risk patients.

Intermittent cEEG review is most common practice.

2. Impact of cEEG on Management Impacts management (60%): NCS identification, AED changes.

3. Non-Convulsive Seizure Epidemiology NCS-NCSE in 50% with ΔMS and acute neurologic disorder.

87% of NCS detected with 1 day cEEG.

Younger, acute convulsions, acute structural brain injury and

epileptiform discharges - increased risk of NCS.

NCS can often be treated with standard AEDs.

Dennis Dlugos

Robert Clancy, Gihan Tennekoon

Alexis Topjian, Robert Berg

Sudha Kessler, Courtney Wusthoff, Eric Marsh

Ana Gutierrez-Colina, Sarah Sanchez

CHOP Neurophysiology Service and FellowsAmir Pshytycky, Raji Mahalingam, Nicole Ryan, Courtney Wusthoff, Karen Skjie, Katie Taub, Saba Ahmad

CHOP Neurology Consult Service

CHOP Neurophysiology Technologists - Maureen Donnelly

Support:

NINDS NSADA

CHOP Department of Pediatrics – Institutional Development Fund

NINDS K23 (NS076550-01)

Are seizures and status

epilepticus associated with worse

outcome?

How can we more efficiently

identify seizures?

How do we best treat seizures in

critically ill children?

How can we implement ICU

cEEG in an appropriate and

feasible manner?

Joshua Goldstein, MDChildren’s Memorial Hospital

Northwestern University

Cecil Hahn, MDHospital for Sick Children

University of Toronto

James Riviello Jr., MDNYU Langone Medical Center

New York University School of Medicine

Susan Herman, MDBeth Israel Deaconess Medical Center

Harvard Medical School

pediatric continuous eeg monitoring: case...

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