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