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P12.1 Nonconvulsive status epilepticus in acute brain injury: a prospective continuous EEG study
S114
Poster presentations: Poster session 12. Neuromonitoring
Conclusions: In this study, EEG monitoring allows early prognosis in patients with TH after cardiac arrest. It appears that for successful recovery, the timescale during which improvement towards a continuous pattern needs to occur is in the order of 24 hours. More patients are enrolled to confirm these findings. P11.15 Continuous EEG-SEP monitoring of acute brain injury in neurointensive care unit S. Fossi1 , R. Carrai1 , A. Amadori2 , L. Bucciardini2 , P. Innocenti2 , C. Cossu1 , S. Gabbanini1 , S. Lori1 , F. Pinto1 , A. Grippo1 , A. Amantini1 1 SOD Neurofisiopatologia, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, 2 SOD Anestesia e TI Neurochirurgica, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy Introduction: Despite the large use of somatosensory evoked potentials (SEPs) for intraoperative monitoring and the proven prognostic utility of SEPs in Acute Brain Injury (ABI) there are only few studies on continuous SEP monitoring in Neuro-ICU (NICU). Objective: To monitor ABI in NICU we used EEG and SEPs in combination to achieve a higher degree of accuracy in detecting deterioration of brain function. Methods: We performed continuous EEG (cEEG) and cycles of SEPs from alternate stimulation of median nerves in comatose patients undergoing ICP monitoring. We displayed conventional and quantitative EEG and SEPs. Results: Since February 2003 to October 2010 we enrolled 118 patients: 52 brain trauma, 17 intracerebral hemorrhages, 43 subarachnoid hemorrhages and 6 ischemic strokes. Mean GCS score on admission was 6 (M4). Mean monitoring time was 8 days. All patients were sedated, 36 underwent TPS. 97 patients were “stable” or improving. In this group SEPs haven’t shown significant changes. 21 (18% of all patients) showed neurological deterioration (11 focal secondary damages and 10 diffuse deteriorations, 11 of them up to cerebral death). In all the 21 deteriorated patients SEPs have shown significant alterations. In 5 patients (24%) SEP deterioration anticipated ICP increase, in 8 (38%) was contemporary and in 7 (33%) SEP deterioration followed ICP increase. In 1 patient (5%) we never had an ICP increase. Based on cEEG we diagnosed nonconvulsive status epilepticus in 4 patients. Conclusions: SEP insensitivity to anesthetics has allowed to monitor the evolution of clinical state even when EEG was scarcely valuable. We noticed that there is a range of values (20 35 mmHg) were ICP increase is an uncertain indication of the occurrence of clinical deterioration, rather are SEP changes able to identify the deterioration of brain function. To our opinion SEPs are a complementary tool that could help the interpretation and management of ICP trends.
Poster session 12. Neuromonitoring
2
P12.1 Nonconvulsive status epilepticus in acute brain injury: a prospective continuous EEG study A. Amantini1 , S. Fossi1 , R. Carrai1 , M. Spalletti1 , A. Amadori2 , L. Bucciardini2 , P. Innocenti2 , C. Cossu1 , G. Lanzo1 , F. Pinto1 , A. Grippo1 1 SOD Neurofisiopatologia, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, 2 SOD Anestesia e TI Neurochirurgica, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy Introduction: Nonconvulsive status epilepticus (NCSE) is reported with very variable incidence in ABI (acute brain injury). Objective: Prospective continuous EEG (cEEG) monitoring in order to diagnose SENC in ABI. Methods: Consecutive patients with GCS < 9 undergoing intracranial pressure (ICP) measurement were monitored in Neuro-ICU (NICU) to detect the evolution of ABI. Continuous digital EEG was acquired with a simplified montage (Fp1-C3-T3-P3, Fp2-C4-T4-P4). Results: Since February 2003 to October 2010 we enrolled 118 patients: 52 traumatic brain injuries (TBI), 17 intracerebral hemorrhage (ICH), 43 subarachnoid hemorrhages (SAH) and 6 ischemic strokes. Mean GCS score on admission was 6 (M4). EEG monitoring started on average 49 hours
2
after admission and 25 hours after NICU admission. Mean monitoring time was 8 days. All patients were sedated, 36 undergoing TPS infusion with EEG suppression. 22 out of the 118 patients (19%) had at least a clinical seizure before EEG monitoring: 18 before ICU admission, 2 both before NICU admission and in NICU, 2 just in NICU. According to the etiology, clinical seizures were observed in 26% of SAH, 13% of TBI, 12% of ICH and 33% of ischemic stroke (2 patients). NCSE was diagnosed in 4 patients (3%). At least a clinical seizure preceded the cEEG diagnosis of NCSE in 3 out of the 4 patients. Conclusions: Our study confirmed the high incidence of clinical seizures in ABI. On the contrary our low incidence of SENC (3%) based on cEEG do not agree with the higher incidence of nonconvulsive seizures/NCSE previously reported. Because we started cEEG on average 49h after the admission we may have missed some case. On the other hand we conducted a prospective EEG study on the evolution of ABI in comatose patients, in which the diagnosis of NCSE was a part of the study. The occurrence of NCSE in patients treated with an ICP-targeted therapy is rare during NICU stay and in most cases is preceded by clinical seizures. P12.2 Role of different neurophysiologic indicators in estimation and prognosis of non-traumatic vegetative state M. Piradov1 Reanimation department, Moscow, Russian Federation
1
The prognostic value of neurophysiologic monitoring (EEG, EEG mapping, polysomnography, Multymodel EP including P300) in different stages of non-traumatic vegetative state (NVS) was evaluated. Material: 23 patients were examined /age was 12 67, NVS occurred after stroke (8); anoxia (10), different encephalopathy (5). In all patients NVS was observed after 10.6 days coma an average. At most duration NVS was 2.5 year (6.7 months an average). 21 patients died. In survived females both anoxia NVS was observed during 14 and 20days, then formation of extrapyramidal hyperkinetic symptomatology and dementia was traced. Results: In full stage of NVS we registered “twinkle” (periods closed to isoline) or “flat” curve (low bioelectric activity < 20 mkV); dominate of delta-- and teta-waves. Cortical components of somatosensory response were weak or absented. Polysomnography sleep “episodes” are absented or presented like brief “insertions” in background state. Our data highlight the presence of sleep fragmentation in NVS, which might be due to changes in brain structures responsible for sleep maintenance. The absence of sleep wake cycles might indicate a poor outcome. During the remission stage (3 cases), when visual fixation occurred, gradual restoration of basic alpha-activity, appearance of activation reaction and cjrtical (even in one side) component of somatosensory EP (SSEP). Smooth and prolongation (up 600 sec) and amplitude reduction of P300 were noted. Predictors of good outcome are less reliable than negative predictors. P12.3 Guiding or confirming value of intraoperative neurophysiological monitoring in intramedullary spinal cord mass lesion surgery S. Ostry1 , L. Stejskal1 , V. Benes1 Department of Neurosurgery, Charles University in Prague, Prague, Czech Republic 1
Objectives: Comparing to historical series, intraoperative neurophysiological monitoring (INM) of motor responses is beneficial in intramedulary spinal cord tumours (IMSCT) surgery. Goals of the study: Ascertain the proportion of INM guided surgery. Find out if proportion of INM guided resections depends on histological type of lesion. Material and Methods: Cohort of consecutive patients operated on IMSCT with obligatory INM in the period 1/2004 9/2010. 64 patients, 14 77 years old, mean: 42.4; 36 males, 28 females. Admission status according to modified McCormick scale (mMCS): 1 2: 40 (62.5%), 3 4: 24 patients (37.5%). Histology: ependymoma 21 (32.8%), astrocytoma 10 (15.6%), cavernoma 10 (15.6%), hemagioblastoma 8 (12.5%), other 15 (23.5%). INM: muscle MEPs (mMEPs) were performed in 64, D-wave in 53 pts (82.8%). Monitorability was in mMEPs: 43 (67.2%), D-wave: 52 (98.1%). All patients had monitorable at least one of motor responses. Significant changes of responses: loss of mMEPs, D-wave amplitude decrease by 50%. Results: Radical resection was achieved in the whole cohort in 43 cases (67.2%) (ependymomas in 16 of 21 pts (76.2%), astrocytomas in 4 of 10 (40%). mMCS 3 months after surgery was 1 2: 42 (65.6%), 3 4: 21
Poster presentations: Poster session 12. Neuromonitoring
Conclusions: In this study, EEG monitoring allows early prognosis in patients with TH after cardiac arrest. It appears that for successful recovery, the timescale during which improvement towards a continuous pattern needs to occur is in the order of 24 hours. More patients are enrolled to confirm these findings. P11.15 Continuous EEG-SEP monitoring of acute brain injury in neurointensive care unit S. Fossi1 , R. Carrai1 , A. Amadori2 , L. Bucciardini2 , P. Innocenti2 , C. Cossu1 , S. Gabbanini1 , S. Lori1 , F. Pinto1 , A. Grippo1 , A. Amantini1 1 SOD Neurofisiopatologia, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, 2 SOD Anestesia e TI Neurochirurgica, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy Introduction: Despite the large use of somatosensory evoked potentials (SEPs) for intraoperative monitoring and the proven prognostic utility of SEPs in Acute Brain Injury (ABI) there are only few studies on continuous SEP monitoring in Neuro-ICU (NICU). Objective: To monitor ABI in NICU we used EEG and SEPs in combination to achieve a higher degree of accuracy in detecting deterioration of brain function. Methods: We performed continuous EEG (cEEG) and cycles of SEPs from alternate stimulation of median nerves in comatose patients undergoing ICP monitoring. We displayed conventional and quantitative EEG and SEPs. Results: Since February 2003 to October 2010 we enrolled 118 patients: 52 brain trauma, 17 intracerebral hemorrhages, 43 subarachnoid hemorrhages and 6 ischemic strokes. Mean GCS score on admission was 6 (M4). Mean monitoring time was 8 days. All patients were sedated, 36 underwent TPS. 97 patients were “stable” or improving. In this group SEPs haven’t shown significant changes. 21 (18% of all patients) showed neurological deterioration (11 focal secondary damages and 10 diffuse deteriorations, 11 of them up to cerebral death). In all the 21 deteriorated patients SEPs have shown significant alterations. In 5 patients (24%) SEP deterioration anticipated ICP increase, in 8 (38%) was contemporary and in 7 (33%) SEP deterioration followed ICP increase. In 1 patient (5%) we never had an ICP increase. Based on cEEG we diagnosed nonconvulsive status epilepticus in 4 patients. Conclusions: SEP insensitivity to anesthetics has allowed to monitor the evolution of clinical state even when EEG was scarcely valuable. We noticed that there is a range of values (20 35 mmHg) were ICP increase is an uncertain indication of the occurrence of clinical deterioration, rather are SEP changes able to identify the deterioration of brain function. To our opinion SEPs are a complementary tool that could help the interpretation and management of ICP trends.
Poster session 12. Neuromonitoring
2
P12.1 Nonconvulsive status epilepticus in acute brain injury: a prospective continuous EEG study A. Amantini1 , S. Fossi1 , R. Carrai1 , M. Spalletti1 , A. Amadori2 , L. Bucciardini2 , P. Innocenti2 , C. Cossu1 , G. Lanzo1 , F. Pinto1 , A. Grippo1 1 SOD Neurofisiopatologia, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, 2 SOD Anestesia e TI Neurochirurgica, DAI Neuroscienze, Azienda Ospedaliera Universitaria Careggi, Florence, Italy Introduction: Nonconvulsive status epilepticus (NCSE) is reported with very variable incidence in ABI (acute brain injury). Objective: Prospective continuous EEG (cEEG) monitoring in order to diagnose SENC in ABI. Methods: Consecutive patients with GCS < 9 undergoing intracranial pressure (ICP) measurement were monitored in Neuro-ICU (NICU) to detect the evolution of ABI. Continuous digital EEG was acquired with a simplified montage (Fp1-C3-T3-P3, Fp2-C4-T4-P4). Results: Since February 2003 to October 2010 we enrolled 118 patients: 52 traumatic brain injuries (TBI), 17 intracerebral hemorrhage (ICH), 43 subarachnoid hemorrhages (SAH) and 6 ischemic strokes. Mean GCS score on admission was 6 (M4). EEG monitoring started on average 49 hours
2
after admission and 25 hours after NICU admission. Mean monitoring time was 8 days. All patients were sedated, 36 undergoing TPS infusion with EEG suppression. 22 out of the 118 patients (19%) had at least a clinical seizure before EEG monitoring: 18 before ICU admission, 2 both before NICU admission and in NICU, 2 just in NICU. According to the etiology, clinical seizures were observed in 26% of SAH, 13% of TBI, 12% of ICH and 33% of ischemic stroke (2 patients). NCSE was diagnosed in 4 patients (3%). At least a clinical seizure preceded the cEEG diagnosis of NCSE in 3 out of the 4 patients. Conclusions: Our study confirmed the high incidence of clinical seizures in ABI. On the contrary our low incidence of SENC (3%) based on cEEG do not agree with the higher incidence of nonconvulsive seizures/NCSE previously reported. Because we started cEEG on average 49h after the admission we may have missed some case. On the other hand we conducted a prospective EEG study on the evolution of ABI in comatose patients, in which the diagnosis of NCSE was a part of the study. The occurrence of NCSE in patients treated with an ICP-targeted therapy is rare during NICU stay and in most cases is preceded by clinical seizures. P12.2 Role of different neurophysiologic indicators in estimation and prognosis of non-traumatic vegetative state M. Piradov1 Reanimation department, Moscow, Russian Federation
1
The prognostic value of neurophysiologic monitoring (EEG, EEG mapping, polysomnography, Multymodel EP including P300) in different stages of non-traumatic vegetative state (NVS) was evaluated. Material: 23 patients were examined /age was 12 67, NVS occurred after stroke (8); anoxia (10), different encephalopathy (5). In all patients NVS was observed after 10.6 days coma an average. At most duration NVS was 2.5 year (6.7 months an average). 21 patients died. In survived females both anoxia NVS was observed during 14 and 20days, then formation of extrapyramidal hyperkinetic symptomatology and dementia was traced. Results: In full stage of NVS we registered “twinkle” (periods closed to isoline) or “flat” curve (low bioelectric activity < 20 mkV); dominate of delta-- and teta-waves. Cortical components of somatosensory response were weak or absented. Polysomnography sleep “episodes” are absented or presented like brief “insertions” in background state. Our data highlight the presence of sleep fragmentation in NVS, which might be due to changes in brain structures responsible for sleep maintenance. The absence of sleep wake cycles might indicate a poor outcome. During the remission stage (3 cases), when visual fixation occurred, gradual restoration of basic alpha-activity, appearance of activation reaction and cjrtical (even in one side) component of somatosensory EP (SSEP). Smooth and prolongation (up 600 sec) and amplitude reduction of P300 were noted. Predictors of good outcome are less reliable than negative predictors. P12.3 Guiding or confirming value of intraoperative neurophysiological monitoring in intramedullary spinal cord mass lesion surgery S. Ostry1 , L. Stejskal1 , V. Benes1 Department of Neurosurgery, Charles University in Prague, Prague, Czech Republic 1
Objectives: Comparing to historical series, intraoperative neurophysiological monitoring (INM) of motor responses is beneficial in intramedulary spinal cord tumours (IMSCT) surgery. Goals of the study: Ascertain the proportion of INM guided surgery. Find out if proportion of INM guided resections depends on histological type of lesion. Material and Methods: Cohort of consecutive patients operated on IMSCT with obligatory INM in the period 1/2004 9/2010. 64 patients, 14 77 years old, mean: 42.4; 36 males, 28 females. Admission status according to modified McCormick scale (mMCS): 1 2: 40 (62.5%), 3 4: 24 patients (37.5%). Histology: ependymoma 21 (32.8%), astrocytoma 10 (15.6%), cavernoma 10 (15.6%), hemagioblastoma 8 (12.5%), other 15 (23.5%). INM: muscle MEPs (mMEPs) were performed in 64, D-wave in 53 pts (82.8%). Monitorability was in mMEPs: 43 (67.2%), D-wave: 52 (98.1%). All patients had monitorable at least one of motor responses. Significant changes of responses: loss of mMEPs, D-wave amplitude decrease by 50%. Results: Radical resection was achieved in the whole cohort in 43 cases (67.2%) (ependymomas in 16 of 21 pts (76.2%), astrocytomas in 4 of 10 (40%). mMCS 3 months after surgery was 1 2: 42 (65.6%), 3 4: 21