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S23. Mortality prediction with the status epilepticus severity score
Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
S23. Mortality prediction with the status epilepticus severity score—Rita L. Aguirre, Mónica B. Perassolo * (Argentina) ⇑
Presenting author.
Introduction: Status epilepticus (SE) as a cause of impaired level of consciousness in intensive care unit (ICU) is reported in the international literature between 5% and 49%, probably underdiagnosed. The many different forms and stages of SE (Refractory SE, RSE and SuperRefractory SE, SRSE) are associated with neuronal injury and require optimal treatment. The Status Epilepticus Severity Score (STESS) was recently developed to predict outcome of SE. AIM: To determine the association between STESS scale and mortality in patients with epileptic status assisted in the ICU of a public hospital. Methods: Analytical, observational and retrospective study of cases of nontraumatic coma with clinical or electroencephalography criteria of SE (classified according to the International League Against Epilepsy, ILAE) admitted to the ICU in a tertiary care hospital in Buenos Aires, Argentina, over a three year period (2014–2017). The STESS scale was used. EEG was recorded using 21 electrodes placed according to the International 10–20 System, at least 60 min of artifact-free recording. We excluded cases with extra-axial brain compression lesions. Results: The cohort consisted of 15 subjects who presented some type of SE, mean age was 49 years ( 18 years), 46% were women, time from ICU admission to first EEG: 2.5 days (1.7 days). A total of 53% of patients had tonic-clonic SE, SRSE (40%) and RSE in the rest of the population. In-hospital mortality rate was 26%. The 86% presented acute brain injury (included stroke, hypoxic-ischemic encephalopathy, metabolic causes, autoimmune encephalitis and infectious encephalitis) and 13% was progressive causes (two patients with brain tumor). A total number of 13 cases (86%), presented with new onset SE without a history of epilepsy and 13% patients had active epilepsy on treatment. STESS scores were significantly higher in non-survivors compared to survivors (P-value = 0.0035). No statistically significant association was found between STESS scores and injury. Patients with STESS scores 63 were found to survive. Follow-up with EEG was useful in 73% patients with SE who recover consciousness once the seizure has been aborted. Conclusion: Despite of the small sample size used in this study, the STESS scale at the admission could predict the evolution of SE. The STESS scores were found to be good predictor of mortality in UCI patients with SE. SE is a very heterogeneous condition in terms of clinical presentation and causes, the application of this scale can help to design better therapeutic regimens for the SE. doi:10.1016/j.clinph.2018.04.383
S24. The combination of electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) for prognostication following anoxic brain injury – A pilot study from an Academic Hospital in Ireland—Kate Flynn *, Ronan Kilbride (Ireland) ⇑
Presenting author.
Introduction: Clinical evaluation for prognosis of comatose patients following hypoxic ischaemic encephalopathy in the intensive care setting is difficult. Electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) both hold value as predictive tools when assessing outcome following cardiac arrest (CA) and hypoxic brain injury. EEG may be used for diagnosis and prognostication on a poorly responsive patient following catastrophic brain injury. There is evidence that loss of EEG reactivity is a strong risk factor for mortality or poor neurological recovery following
e151
cardiac arrest, however, bilaterally absent SSEPs remain the most reliable predictor of poor outcome. SSEPs have not been widely available in Ireland as a component of neurophysiologic investigation following hypoxic ischaemic encephalopathy. The aim of this review is to assess and compare the predictive value of EEG and SSEP separately as single modality testing and then subsequently combine both tests for a multimodal approach to predict poor outcome following anoxic brain injury. Is a multimodal approach mandatory? Methods: Seventeen cardiac arrest survivors were included in this review. We adopted a multimodal approach to neurophysiologic investigations in the ICU setting with prospective evaluation of patients of hypoxic ischaemic encephalopathy after CA. EEG and SSEPs were performed at normothermia. EEG background reactivity to painful stimulation was tested. Results: Of the 17 patients included in the review, two survived to discharge and 15 subsequently died during hospitalisation. EEG was utilised as a marker for poor outcome combining malignant EEG patterns and absent reactivity of background rhythms. 11 out of 17 fitted into the ‘‘poor outcome” category for EEG, all of whom died. Bilateral absent N20 cortical responses were utilised for poor outcome, 9 out of 17 fitted into the ‘‘poor outcome” category, all of whom went on to die. However, there were eight patients included showing present N20s, this is not prognostic of a favourable outcome. A combination of EEG and SSEP was needed to predict outcome. The EEG showed malignant EEG patterns and unreactive background in 2 of the present N20 patients who subsequently went on to die. Conclusion: The EEG represents a useful tool for prognostic assessment. Unreactive EEG background and malignant EEG patterns are incompatible with good long term recovery. In settings without access to SSEPs this can be helpful, however, a bilaterally absent somatosensory evoked potential is still the most reliable predictor for poor outcome. Throughout our review a multimodal approach is shown to be favourable when assessing Hypoxic Ischemic Encephalopathy. This approach, as described above, was necessary to predict outcome in cases where the N20 cortical response was present, thus optimising prognostic accuracy when assessing hypoxic brain injury in the ICU. Early identification of patients without the potential for recovery of brain function may result in unnecessary prolongation of medical therapy. doi:10.1016/j.clinph.2018.04.384
S25. Prognostic value of N20 amplitude in patients with postanoxic coma—Misericordia Veciana de las Heras *, Jordi Pedro, Belia Garcia Parra, Sara Yagüe, Maria Jose Castro Castro, Claudia Elisabeth Imperiali, Antonio Martínez-Yélamos (Spain) ⇑
Presenting author.
Introduction: Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) is a reliable predictor of poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation. However the preservation of N20 does not prognosticate awakening, in fact is an uncertain pattern. The prognostic value of N20 amplitude has still not been sufficiently documented. In our knowledge only one study has analyzed N20 amplitude. The aim of this study was to review the relationship between N20 amplitude and neurological outcome in our postanoxic patients. Methods: We retrospectively review the data of all our patients who remained comatose after cardiopulmonary resuscitation between 2013 and 2017. The following variables were collected:
S23. Mortality prediction with the status epilepticus severity score—Rita L. Aguirre, Mónica B. Perassolo * (Argentina) ⇑
Presenting author.
Introduction: Status epilepticus (SE) as a cause of impaired level of consciousness in intensive care unit (ICU) is reported in the international literature between 5% and 49%, probably underdiagnosed. The many different forms and stages of SE (Refractory SE, RSE and SuperRefractory SE, SRSE) are associated with neuronal injury and require optimal treatment. The Status Epilepticus Severity Score (STESS) was recently developed to predict outcome of SE. AIM: To determine the association between STESS scale and mortality in patients with epileptic status assisted in the ICU of a public hospital. Methods: Analytical, observational and retrospective study of cases of nontraumatic coma with clinical or electroencephalography criteria of SE (classified according to the International League Against Epilepsy, ILAE) admitted to the ICU in a tertiary care hospital in Buenos Aires, Argentina, over a three year period (2014–2017). The STESS scale was used. EEG was recorded using 21 electrodes placed according to the International 10–20 System, at least 60 min of artifact-free recording. We excluded cases with extra-axial brain compression lesions. Results: The cohort consisted of 15 subjects who presented some type of SE, mean age was 49 years ( 18 years), 46% were women, time from ICU admission to first EEG: 2.5 days (1.7 days). A total of 53% of patients had tonic-clonic SE, SRSE (40%) and RSE in the rest of the population. In-hospital mortality rate was 26%. The 86% presented acute brain injury (included stroke, hypoxic-ischemic encephalopathy, metabolic causes, autoimmune encephalitis and infectious encephalitis) and 13% was progressive causes (two patients with brain tumor). A total number of 13 cases (86%), presented with new onset SE without a history of epilepsy and 13% patients had active epilepsy on treatment. STESS scores were significantly higher in non-survivors compared to survivors (P-value = 0.0035). No statistically significant association was found between STESS scores and injury. Patients with STESS scores 63 were found to survive. Follow-up with EEG was useful in 73% patients with SE who recover consciousness once the seizure has been aborted. Conclusion: Despite of the small sample size used in this study, the STESS scale at the admission could predict the evolution of SE. The STESS scores were found to be good predictor of mortality in UCI patients with SE. SE is a very heterogeneous condition in terms of clinical presentation and causes, the application of this scale can help to design better therapeutic regimens for the SE. doi:10.1016/j.clinph.2018.04.383
S24. The combination of electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) for prognostication following anoxic brain injury – A pilot study from an Academic Hospital in Ireland—Kate Flynn *, Ronan Kilbride (Ireland) ⇑
Presenting author.
Introduction: Clinical evaluation for prognosis of comatose patients following hypoxic ischaemic encephalopathy in the intensive care setting is difficult. Electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) both hold value as predictive tools when assessing outcome following cardiac arrest (CA) and hypoxic brain injury. EEG may be used for diagnosis and prognostication on a poorly responsive patient following catastrophic brain injury. There is evidence that loss of EEG reactivity is a strong risk factor for mortality or poor neurological recovery following
e151
cardiac arrest, however, bilaterally absent SSEPs remain the most reliable predictor of poor outcome. SSEPs have not been widely available in Ireland as a component of neurophysiologic investigation following hypoxic ischaemic encephalopathy. The aim of this review is to assess and compare the predictive value of EEG and SSEP separately as single modality testing and then subsequently combine both tests for a multimodal approach to predict poor outcome following anoxic brain injury. Is a multimodal approach mandatory? Methods: Seventeen cardiac arrest survivors were included in this review. We adopted a multimodal approach to neurophysiologic investigations in the ICU setting with prospective evaluation of patients of hypoxic ischaemic encephalopathy after CA. EEG and SSEPs were performed at normothermia. EEG background reactivity to painful stimulation was tested. Results: Of the 17 patients included in the review, two survived to discharge and 15 subsequently died during hospitalisation. EEG was utilised as a marker for poor outcome combining malignant EEG patterns and absent reactivity of background rhythms. 11 out of 17 fitted into the ‘‘poor outcome” category for EEG, all of whom died. Bilateral absent N20 cortical responses were utilised for poor outcome, 9 out of 17 fitted into the ‘‘poor outcome” category, all of whom went on to die. However, there were eight patients included showing present N20s, this is not prognostic of a favourable outcome. A combination of EEG and SSEP was needed to predict outcome. The EEG showed malignant EEG patterns and unreactive background in 2 of the present N20 patients who subsequently went on to die. Conclusion: The EEG represents a useful tool for prognostic assessment. Unreactive EEG background and malignant EEG patterns are incompatible with good long term recovery. In settings without access to SSEPs this can be helpful, however, a bilaterally absent somatosensory evoked potential is still the most reliable predictor for poor outcome. Throughout our review a multimodal approach is shown to be favourable when assessing Hypoxic Ischemic Encephalopathy. This approach, as described above, was necessary to predict outcome in cases where the N20 cortical response was present, thus optimising prognostic accuracy when assessing hypoxic brain injury in the ICU. Early identification of patients without the potential for recovery of brain function may result in unnecessary prolongation of medical therapy. doi:10.1016/j.clinph.2018.04.384
S25. Prognostic value of N20 amplitude in patients with postanoxic coma—Misericordia Veciana de las Heras *, Jordi Pedro, Belia Garcia Parra, Sara Yagüe, Maria Jose Castro Castro, Claudia Elisabeth Imperiali, Antonio Martínez-Yélamos (Spain) ⇑
Presenting author.
Introduction: Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) is a reliable predictor of poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation. However the preservation of N20 does not prognosticate awakening, in fact is an uncertain pattern. The prognostic value of N20 amplitude has still not been sufficiently documented. In our knowledge only one study has analyzed N20 amplitude. The aim of this study was to review the relationship between N20 amplitude and neurological outcome in our postanoxic patients. Methods: We retrospectively review the data of all our patients who remained comatose after cardiopulmonary resuscitation between 2013 and 2017. The following variables were collected: