Dr. Khoo Teik Beng
Paediatric Institute
Hospital Kuala Lumpur
What is critical care EEG monitoring?
Indications
Electrographic seizures – Does it matter?
IPHKL’s experience
Short term
Long-term / Continuous (cEEG)
Amplitude-integrated EEG (aEEG)
Indications
Seizure or not seizure?
What’s going on?
Brain death assessment
About ½ of the patients with seizures are
identified in the first hour
90% are identified within first 24 hours
However, as cEEG is resource-intensive, the
duration should be tailored to the individual
patient, clinical status and etiology of the
acute encephalopathy
Abend NS et al, J Clin Neurophysiol 2013
Refractory status epilepticus
Acute encephalopathy
With prior clinical seizures
With acute brain injury
Unexplained
Neuromuscular blockade, with acute brain
injury
Characterization of clinical events suspected
to be seizures
Intracranial pressure management
Abend NS et al, 2013
Status epilepticus
Traumatic brain injury (accidental, NAI)
HIE (neonatal, cardiac arrest, near drowning)
ECMO therapy
Ischaemic or haemorrhagic stroke
Post-cardiac surgery
Post-neurosurgery
Acute metabolic encephalopathy (sepsis, hepatic, renal)
Abend NS et al, 2013
Rapid EEG improvement over hours
Reactivity
Normal sleep pattern
Abend et al, Curr Neurol Neurosci Rep. 2013
Burst suppression
Excessive discontinuity
Severe attenuation
Lack of reactivity
Abend et al, Curr Neurol Neurosci Rep. 2013
Abnormal, paroxysmal EEG events that differ
from the background activity, last longer
than 10 seconds, have a plausible
electrographic field, and evolve in frequency,
morphology and spatial distribution
May be convulsive or non-convulsive
Abend NS et al, 2013
Abend NS et al, 2013
Electroclinical
seizures
EEG-only
seizures
(subclinical)
Clinically
apparent
seizures
Subtle
seizures
Uninterrupted electrographic seizures lasting
30 minutes or longer
or
Repeated electrographic seizures totaling
> 30 minutes in any one-hour period
May be convulsive or non-convulsive
Abend NS et al, 2013
Does Electrographic
seizures matter?
Neurology 2014
Wagenman et al
60 patients
Male : Female 37: 23
Age : 1 months – 12 years old (median : 11 m)
Type of EEG monitoring:- Routine (<1 hour) 40
Short-term (1-2 hours) 7
Prolonged (2-8 hours) 10
cEEG / Overnight 13
aEEG 4
Repeated EEG 13
Indications n %
1 TRO Seizures
21 35.0
2 Acute encephalopathy
14 23.3
3 Post-status epilepticus
11 18.3
4 Brain death assessment
5 8.3
5 Seizure aggravation
5 8.3
6 Refractory status epilepticus
4 6.7
TRO Seizures
(n=21)
Non-epileptic events
(14, 66.7%)
Electrographic seizures
(4, 19%)
Electroclinical seizures
(1, 4.8%)
No event captured
(6, 28.6%)
Hand shaking,, leg shaking, leg stiffening, head
shaking, sucking, lip smacking
Non-epileptic myoclonus
Choreiform movement, orobuccal dyskinesia
Video 1
Video 2
Often seen after weaning down / off sedation
Intermittent agitation, sweating, dystonia,
↑T, ↑HR, ↑BP
Visit our poster!
Video 3
FIRES with BS pattern after given boluses of iv phenobarbitone
Right Frontal
Left Frontal
Right Temporal
Left Temporal
Boluses of iv Phenobarbitone
aEEG of a patient
with FIRES
“Making peace with
FIRES”
PLEASE VISIT THE EXHIBITION BOOTH!
To the Patients Burn marks / pressure sore
To the PICU Nursing
To EEG Neurotechnicians Leads disconnection
High impedance
On call
To the Neurologist Urgent reporting / review
The practice of critical care EEG monitoring
varies a lot across centers.
Increase in EEG requests but it remains
labour-intensive
Electrographic status epilepticus confers
poor outcome