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
American Epilepsy Society | Annual Meeting
Learning Objectives
This case provides a framework for considering how continuous EEG monitoring is used in the
pediatric intensive care setting.
American Epilepsy Society | Annual Meeting
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
American Epilepsy Society | Annual Meeting
Disclosure
None.
American Epilepsy Society | Annual Meeting
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.
American Epilepsy Society | Annual Meeting
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2010 Philadelphia Abend NS, unpublished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
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).
Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care 2010.
1. Current Practice - cEEG & NCS Management
2. Impact of cEEG on Management
3. Non-Convulsive Seizure Epidemiology
“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.
1. Current Practice - cEEG & NCS Management
2. Impact of cEEG on Management
3. Non-Convulsive Seizure Epidemiology
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
Critically ill and underwent
cEEG >62% 38%
McCoy
2011
121
Neo+Ped
Critically ill and underwent
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
underwent cEEGRetro 38%
Hosain 2005178
Neo+Ped
Persistently
unresponsiveRetro 33%
McCoy 2011121
Neo+Ped
Critically ill and
underwent cEEGRetro 29%
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
Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care 2010.
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