rosen - aeeg beyond the nicu (2)

8/7/2019 Rosen - aEEG beyond the NICU (2)

http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 1/19Ingmar Rosen, MD: Jan. 17, 2008

Amplitude integrated EEGbeyond the NICU

Ingmar RosénDivision of Clinical NeurophysiologyDepartment of Clinical Science Lund

Lund University

•Restoration of EEG background

•Detection of seizure events>> SEPrior and Maynard

Old CFM in neonatal monitoring

10 daysof CFM !



Old CFM-problems

• Artefacts (movements,care procedures,

ECG, high frequency ventilation)

• Lack of correllation with the original EEGsignal.

• Neonatal aEEG interpretation became anart of its own, independent of the vastEEG-knowledge/experience

CFM/aEEG development

New aEEG/EEG

• Shows the real EEG

• Stores digital EEG, available for review

and reanalysis

• Flexibility – trends, number of

channels, time resolution

New aEEG/EEG monitors by: BrainZ,Viasys, Olympic, Micromed, Day One



Patterns discernable by simplified

aEEG/EEG monitoring

• Pathology of EEG background-prognosis

• Monitoring before-during-afterhypothermia

• Seizure patterns-possibility to treat

Applications of aEEG trend monitoring in

paediatric neurology beyond the NICU

• Monitoring of Status Epilepticus and follow up ofacute treatment

• Detection of rare seizure patterns in immobilizedchildren

• Useful tool in full video-EEG monitoring

• Contributes to prognosis after severe ishemic

insult/cardiac arrest

aEEG and SE monitoring

• The additional value of aEEG monitoring is

depending upon type and EEG features ofthe SE

• An early full EEG is recommended and isoften used for tailoring the monitoring



EEG message in SE

High intensityseizure pattern

Risk of excitotoxic

injury

Repetitive focalor generalizedspiking

Immediate interferencewith cognition/consciousness

ESESCSWSEpileptic encephalopathyof childhood

Deleterious plasticeffects on brainfunctional development

Progress of generalized convulsive SE

(Treiman)

Start of clinical seizure



Continuous generalized seizure pattern

EEG

Seizurepattern arrested by propofol

Continuous EEG

EEG

Seizurepattern arrested by propofol

Burst-Suppression pattern



Status epilepticus (AD-2003)

• 4 y girl

• Olfactory neuroblastoma, posteriorfossa+front dx

• Post op unconscious suspected seizures

• Full EEG

• 2 channel aEEG/EEG monitoring

AD-2003


http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 7/19



Focal seizures and limitednumber of recording channels

How serious is the problem ?

With tailored design sufficient sensitivity isattained with few recording channels (and

electrodes)

The brain is a volumeconductor

P3-P4

C3-P3

C4-P4

A

B

C

3 focalseizureswith different locations all appear in one channel aEEG trace



TN (severe epilepticencephalopathy)

• Girl born 34+5 w. Pre-eclampsia.

• 6d gen seiz ; Phbarb, Fos-phen, Midazol.• Seizure free from 10 d

• 2 m foc seiz left eye+ hand + gen ton s

• Repeated seizure periods

• 5 m EEG: Hypsarrythmia. Therapy resistent

• 11m Ketogenic diet with some improvement;several seizure types

TN 2 m seizure

TN 2 m ii



TN 2 m i

TN 11 m

TN 11 m



aEEG and SE monitoring

• The additional value of aEEG monitoring is dependingupon type and EEG features of the SE

• An early full EEG is recommended and is often used fortailoring the monitoring

• Flexibility of channel number, position, and trend mode isan advantage

• 2 channel (F3-P3; F4-P4) aEEG/EEG recordingrecommended after the neonatal period

Acute EEGFinal

SumupMonitortailored

Monitor

standardEEG

FinalSumup

Green hours

Red hours

Monitor

tailored

Seizure detection (EK-2007)

• 7 m girl with achondroplasia

• Decompressive surgery posterior fossa

• Post op hiccups and apnoeic episodes• Full EEG: diffuse slowing-no epileptiform

activity

• Seizures ?



EK-2007

1

2

3

1

2

3

EK-2007

Suspected seizures (AG-2003)

• 4 y girl from Kosovo

• Severe perinatal cerebral lesion

( mechonium aspiration reported)

• Severe dystonic CP

• Microcephaly with extensive cortical and whitematter lesions

• EEG: pathological with interictal positive sharpwaves right side

• Frequent attacks of extension –seizures ?



AG-2003

AG-2003

AG-2003



AG-2003

Video-EEG(HL-2002)

• 5y girl

• Short history of focal epilepsy

• Subtle episodes with absense sometimesdrawling, sometimes subtle jerks right partof face.

• Tumor left hemisphere (PAD: multifocalmalignant PNET)

HL 2002 vEEG



aEEG monitoring of recoveryafter global brain ischemia

Watanabe

Prior and Maynard

Acuteeffects of global brain ischemia and recovery

Gavilanes

CA+ROSC Normothermia Neurol ex Neurol ex

Targettemp

Cooling Rewarm

4h 24h 8h 24h 48h

ContinuousaEEGmon

2chC3-P3C4-P4

SSEPMR

SSEPMR

11

2

33

4

EP

N13

P14

N18

N20

P25 1 uV10 ms

EP N13

P14

N18

N20/P25

iE-cE

C5-cE

Fz-cEcCP-Fz

Continuous aEEG/EEG monitoring duringand after hypothermiatreatmentfollowing cardiac arrest in adults- study designRundgren, Rosén, Friberg. Intensive Care Medicine 2006



A B

C D

Flat S-B

Continuous

SE

34 patients

CPC1: 112:63:3

ContinuousEEG

withoutESE

n=20

Flat: 5SB: 3

ESE: 6

CPC1-3:05:14

Table 1: Cerebral Performance Category (CPC) scale

CPC 1: Good cerebral performance: conscious, alert, able to work

CPC 2: Moderate cerebral disability: conscious, can carry out independentactivities

CPC 3: Severe neurological disability: conscious, dependent on others for dailysupport

CPC 4: Coma or vegetative state

CPC 5: Dead

Conclusion

• Continuous simplified aEEG monitoring is

technically feasible in the adult ICU

• The EEG pattern at normoterm (36h) butnot within the first few hours predicsoutcome in terms of survival

• Continuous epileptiform activity with onset

within 24 h after CA is a serious predictivesign.

Rundgren,Rosén,FribergIntCare Med 2006



aEEG-monitoring after severeasphyxia and cardiac arrest

(EL-88)

• Girl 17 y• Came under a dead horse during horse

competition

• RLS 8 when rescucitated after 15 min.

• Hypothermia treatment for 48h

0 d

2 d

EL-88

1 d

aEEG-monitoring after cardiacarrest (ZE-91)

• 16 y boy

• Ventricular fibrillation

• Rapid rescusitation-45 min to spont.cirk.• Initially unconscious

• Hypothermia treatment



1 d

2d

ZE-91

Applications of aEEG trend monitoring in

paediatric neurology beyond the NICU

• Monitoring of Status Epilepticus

• Detection of rare seizure patterns in immobilizedchildren

• Useful tool in full video-EEG monitoring fordetection of clinically silent seizures

• Adds prognostic information after severeischemic insult/cardiac arrest

• Full EEG and aEEG/EEG combined isimperative in most cases

NFK

UMAS

NICU

Mobile

unit

NICU

CHICU

ICU

Stroke

NL

Mobile

ICU

Server

NFK

USiL

Networking facilitatesInterdisciplinary interaction !

rosen - aeeg beyond the nicu (2)

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