- Email: [email protected]
S28. Survival in patients admitted in an intensive care unit according to electroencephalographic patterns
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Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
N20 amplitude, clinical examination, EEG data, neuron-specific enolase and outcome determined upon hospital discharge by means of Cerebral performance category (CPC). The patients with CPC 1–3 were defined as good outcome, and those with CPC 4–5 as poor outcome. Results: We identified 76 postanoxic patients with N20 present. Fifty-three (69.7%) had poor outcome (CPC 4–5). The mean N20 amplitude in these patients was 1.90 lV (SD 2.01 range 0.16–7.9). Twenty-three patients (30.2%) had good outcome (CPC 1–3) and the mean N20 amplitude in these patients was 3.43 lV (SD 2.73 range 0.93–11.3). The ROC curve shows 0.86 lV as the cut-value for a better specificity with higher sensitivity. Any patient with amplitude lowest than 0.86 lV had good outcome (specificity 100%, sensitivity 50.9%, positive predictive value 100%, negative predictive value 46.9%). Conclusion: In our postanoxic patients very low N20 amplitudes appear to be highly predictive of poor outcome. Our results corroborate published data. doi:10.1016/j.clinph.2018.04.385
S26. Description and prognostic value of EEG in patients in coma after recovered cardiorespiratory arrest—Raidili Mateo-Montero, Guillermo Martin-Palomeque, Carlos Valera, Alicia GómezAnsede, Antonio Pedrera-Mazarro, Liliana González-Rodriguez, Ignacio Regidor (Spain)
Introduction: Postanoxic coma after cardiac arrest is one of the most serious acute cerebral conditions and a frequent cause of admission to critical care units, wherefore is necessary the use of accurate methods for diagnosis and prognosis. In addition to the classic neurologic examination, EEG is increasingly emerging as an important tool to assess cerebral functions in a non-invasive way because is a sensitive method for evaluating patients with anoxicischaemic encephalopathy due to cardiorrespiratory arrest (CRA) and provides accurate prognostic information in the early phase of coma however, its specificity is affected by the action of sedative drugs and the variability inter-observers. The EEG shows several patterns that may be useful for the prognosis and possible progression of patients with post-CRA coma. The aim of this study is to describe the morphology and analyze the prognostic value of the EEG patterns and reactivity to stimuli in post-CRA coma patients. Methods: 45 patients with CRA were analyzed. The variables established in the study included age, sex, pathological history, time of CRA, cause of CRA, therapeutic hypothermia, EEG (pattern and reactivity) and clinical development. All EEG studies were done without sedation drugs at least for 8 h and 24 h after therapeutic hypothermia (TH). Results: The initial EEG and the control EEGs in the patients were analyzed and an attempt was made to establish a correlation between the various EEG patterns and the clinical evolution of the patients. Surprisingly, the EEG reactivity was the parameter that, in isolation, presented greater specificity in our series. Conclusion: The EEG provides early information on brain function and prognosis in the context of a multimodal assessment of coma patients with recovered CRA. The standardization in the nomenclature of the EEG patterns following the terminology of the ACNS helps the easy recognition of these patterns and their correlation with the prognosis. It is essential to evaluate reactivity in this patients, given that this seems to be the most relevant data when estimating a prognosis. doi:10.1016/j.clinph.2018.04.386
S27. Outcome prediction in postanoxic coma with deep learning—Jeannette Hofmeijer, Barry J. Ruijter, Albertus Beishuizen, Frank H. Bosch, Michel J. van Putten, Marleen C. TjepkemaCloostermans * (Netherlands) ⇑
Presenting author.
Introduction: Visual assessment of the electroencephalogram (EEG) by experienced clinical neurophysiologists allows reliable outcome prediction in up to half of all comatose patients after cardiac arrest. We hypothesize that deep neural networks can achieve similar or better performance, while being objective and consistent. Methods: In a prospective cohort study, continuous EEG recordings from comatose patients after cardiac arrest were collected from the intensive care units of two large teaching hospitals. Functional outcome at six months was assessed using the Cerebral Performance Category scale (CPC), dichotomized as good (CPC 1–2) or poor (CPC 3–5). Five-minute artifact-free EEG epochs at 12 and 24 h after cardiac arrest were partitioned into 10 s epochs. We trained a convolutional neural network, using the raw EEG epochs and outcome labels as inputs to predict outcome using data from 80% of the patients. Validation was performed in the remaining 20%. The probability of recovery to good neurological outcome was quantified for each individual patient. Analyses of diagnostic accuracy included receiver operating characteristics and calculation of predictive values at 12 and 24 h. Results: Four hundred and fifty-six patients were included, resulting in 306 and 439 EEGs epochs at 12 and 24 h, respectively. Outcome prediction was most accurate at 12 h, with an area under the ROC curve (AUC) of 0.89 versus 0.81 at 24 h. Poor outcome could be predicted at 12 h with a sensitivity of 62% (95% confidence interval (CI): 45–78%) at false positive rate (FPR) of 0% (CI: 0–14%); good outcome could be predicted at 12 h with a sensitivity of 50% (CI: 29– 71%) at a FPR of 5% (CI: 1–18%). Conclusion: Deep learning of raw EEG signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual assessment by trained EEG expert. Our approach offers the potential for objective and real-time insight in the prognosis of neurological outcome on a continuous scale, and can provide low-cost expertise at the bedside. doi:10.1016/j.clinph.2018.04.387
S28. Survival in patients admitted in an intensive care unit according to electroencephalographic patterns—Mónica B. Perassolo *, Rita L. Aguirre (Argentina) ⇑
Presenting author.
Introduction: The American Society of Neurophysiology implemented a standardized classification (ACNS Standardized) for the evaluation of cerebral electrical activity in critical patients. The interpretation of electroencephalogram (EEG) findings and clinical correlation is still in debate. AIM: To compare survival according to EEG periodic and not periodic pattern in patients hospitalized in an intensive care unit. Methods: Retrospective cohort of patients over 16 years, in coma state, hospitalized consecutively at the intensive care unit (ICU) in a tertiary care hospital in Buenos Aires, Argentina, from 2014 to 2017. We included all patients with at least one 60 min EEG performed at the ICU, registered according to the International System 10/20. We excluded cases with extra-axial compression injuries. We used the ACNS Standardized guidelines (v.2012), Glasgow Outcome Scale (GOS) and Charlson’s comorbidity index (CCI). We
Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
describe the population according to a periodic pattern (PP) and not periodic (NoPP), and compared characteristics between them. We estimate survival during hospitalization at ICU using the Kaplan– Meier method and compared survival between groups with a log rank test. Results: We included 60 patients, mean age was 57 years (SD 18), 41.7% (25) were female. The median stay in ICU was 28 days (IQR 11.5-48). Thirty percent (12) were classified as PP and 70% (48) as NoPP. Comparing baseline characteristics between groups PP vs NoPP, female proportion was (72.2% vs 28.6%; p = 0.01), age (66.1 vs 56.5 years; p = 0.23), CCI (1.5 vs 1; p = 0.58), etiology (intra-axial compressive injuries 11.1% vs destructive injuries 19%; p = 0.46) and time from ICU admission to first EEG (3 vs 4; p = 0.81), respectively. Survival in ICU was for PP vs NoPP was 61.29% (CI95% 33.3– 80.4) vs 79.4% (CI95% 61.6–89.6) p = 0.11, respectively. Functional prognostic at discharge measured as GOS 6 2 was 50% (9) and 38.1% (16) p = 0.41 for PP vs NoPP. Conclusion: A lower in hospital survival was observed in patients admitted to the ICU with a periodic electroencephalographic pattern and a worse functional prognosis compared with patients with nonperiodic pattern. Although this difference is not statistically significant, due to the small sample, we question if pattern detection can define clinical prognosis and mortality in patients at the intensive care unit. doi:10.1016/j.clinph.2018.04.388
S29. rTMS application in disorders of consciousness—Alexandra Poydasheva *, Liudmila Legostaeva, Elizaveta Mochalova, Elena Kremneva, Dmitri Sinitsyn, Dmitri Sergeev, Natalia Suponeva, Julia Ryabinkina, Michael Piradov (Russian Federation) ⇑
Presenting author.
Introduction: There is an unmet need in effective neurorehabilitation methods in chronic disorders of consciousness (DOC). Noninvasive brain stimulation, such as navigated rTMS, is a perspective tool for modulation of the cerebral networks activity in such patients, and resting FMRI, that allows estimating the neural networks activation and interactions, may indicate the target for precise stimulation. Patients with severe brain damage after anoxia or trauma who survived coma, show selective activation of the default mode network (DMN), particularly, gyrus angularis, as the level of consciousness increases. Here, we studied effects of high-frequency navigated rTMS on gyrus angularis as a new approach for the chronic DOC rehabilitation. Methods: We included 10 patients with post-anoxic VS (median age 39.3, mean CRS-R score 5.1); 8 patients with post-anoxic MCS (median age 45.8, mean CRS-R score 14.4); 4 patients with traumatic VS (median age 22.3, mean CRS-R 5.8), and 5 traumatic MCS patients (median age 45.8, mean CRS-R 14.4). EEG revealed no seizure-like electric activity. Individual activation assessed by resting fMRI represented DMN activation including left gyrus angularis area in MCS patients, with no activation of DMN in VS patients. Against the background of standard rehabilitation program (motomed letto IIassisted mechanical therapy, massage, passive joints movements) we provided high-frequency rTMS on the gyrus angularis (10 sessions of stimulation with 20 Hz, 2400 stimulus 90% MT). Consciousness level was assessed with CRS-R scale by the same independent rater before and after stimulation course. Results: CRS-R score increased in the patients with the residual signs of consciousness behavior (MCS). Median increase in CRS-R score after neurorehabilitation course was 2 points. However, we found no change in clinical assessment in the VS cases. No side
e153
effects of the rTMS were observed. Correlation of CRS-r score in permanent disorders of consciousness before and after rTMS course on gyrus angularis. Conclusion: The course of the high-frequency TMS with navigation on gyrus angularis is a potentially effective method of rehabilitation in permanent disorders of consciousness. We obtained clinical effect in states of the minimal signs of consciousness, but not in VS. These results are advisable to continue researches in studies of this new protocol’s effectiveness. The study is supported by Russian Science Foundation grant No. 16-15-00274. doi:10.1016/j.clinph.2018.04.389
S30. Immediate or retarded nerve repair—Clara Nevado *, Juan Pablo Aguado, Antonia Garcia (Spain) ⇑
Presenting author.
Introduction: We presented two cases with complete ulnar nerve section at the very same level, antebrachial region, below branches to flexor digitorum profundus, one with immediate repair and the other with delay repair of about three months. Methods: The delay repair and the immediate repair nerves were at the same month, we make them an EMG at eight weeks from repair and every four weeks until reinnervation took place (motor units seen at abductor digiti minimi). Also echography was done to ensure cubital growing. Age was similar for boths patients, gender: one man (delay) other woman (immediate). Rehabilitation techniques were the same for all of them. Also de the surgeon was the same in all two. Results: Time for reinnervation at the immediate repair was at nine months after the epineural end-to-end repair. Time for reinnervation at the delay repair was five months after a sural nerve graft was used ( eight months after ulnar lesion). Of the two patients the delay repair has had better reinnervation (force 3/5) while the immediate repair ended with 2/5 force and also an ulnar neuroma was seen and removed, months after the nerve reached abductor digiti minimi. Conclusion: As we observed in these particular cases, time is more or less the same in both cases regardless of the technique to repair nerve, probably first is the inflammation phase plus wallerian degeneration, so useful reinervation takes place later, so probably delay repair is not as usefulness as it has been proposed, if it is doing in the right time, after inflammation phase has ended probably avoiding neuroma formation and less endoneural fibrosis, and also we need to search for others ways to avoid inflammation after nerve section to elevate prognosis. doi:10.1016/j.clinph.2018.04.390
S31. Guillain–Barré syndrome outcome at Cipto Mangunkusumo Hospital Jakarta Indonesia—Ahmad Y. Safri *, Ramdinal Avisenna, Luh Ari Indrawati, Fitri Octaviana, Manfaluthy Hakim (Indonesia) ⇑
Presenting author.
Introduction: Erasmus GBS Outcome Score (EGOS) is a model to predict the outcome of patients after GBS. EGOS studies were conducted in well developed countries, which have different patient characteristics and medical facility than in the middle-income country like Indonesia. In the middle-income country, the prognosis
Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
N20 amplitude, clinical examination, EEG data, neuron-specific enolase and outcome determined upon hospital discharge by means of Cerebral performance category (CPC). The patients with CPC 1–3 were defined as good outcome, and those with CPC 4–5 as poor outcome. Results: We identified 76 postanoxic patients with N20 present. Fifty-three (69.7%) had poor outcome (CPC 4–5). The mean N20 amplitude in these patients was 1.90 lV (SD 2.01 range 0.16–7.9). Twenty-three patients (30.2%) had good outcome (CPC 1–3) and the mean N20 amplitude in these patients was 3.43 lV (SD 2.73 range 0.93–11.3). The ROC curve shows 0.86 lV as the cut-value for a better specificity with higher sensitivity. Any patient with amplitude lowest than 0.86 lV had good outcome (specificity 100%, sensitivity 50.9%, positive predictive value 100%, negative predictive value 46.9%). Conclusion: In our postanoxic patients very low N20 amplitudes appear to be highly predictive of poor outcome. Our results corroborate published data. doi:10.1016/j.clinph.2018.04.385
S26. Description and prognostic value of EEG in patients in coma after recovered cardiorespiratory arrest—Raidili Mateo-Montero, Guillermo Martin-Palomeque, Carlos Valera, Alicia GómezAnsede, Antonio Pedrera-Mazarro, Liliana González-Rodriguez, Ignacio Regidor (Spain)
Introduction: Postanoxic coma after cardiac arrest is one of the most serious acute cerebral conditions and a frequent cause of admission to critical care units, wherefore is necessary the use of accurate methods for diagnosis and prognosis. In addition to the classic neurologic examination, EEG is increasingly emerging as an important tool to assess cerebral functions in a non-invasive way because is a sensitive method for evaluating patients with anoxicischaemic encephalopathy due to cardiorrespiratory arrest (CRA) and provides accurate prognostic information in the early phase of coma however, its specificity is affected by the action of sedative drugs and the variability inter-observers. The EEG shows several patterns that may be useful for the prognosis and possible progression of patients with post-CRA coma. The aim of this study is to describe the morphology and analyze the prognostic value of the EEG patterns and reactivity to stimuli in post-CRA coma patients. Methods: 45 patients with CRA were analyzed. The variables established in the study included age, sex, pathological history, time of CRA, cause of CRA, therapeutic hypothermia, EEG (pattern and reactivity) and clinical development. All EEG studies were done without sedation drugs at least for 8 h and 24 h after therapeutic hypothermia (TH). Results: The initial EEG and the control EEGs in the patients were analyzed and an attempt was made to establish a correlation between the various EEG patterns and the clinical evolution of the patients. Surprisingly, the EEG reactivity was the parameter that, in isolation, presented greater specificity in our series. Conclusion: The EEG provides early information on brain function and prognosis in the context of a multimodal assessment of coma patients with recovered CRA. The standardization in the nomenclature of the EEG patterns following the terminology of the ACNS helps the easy recognition of these patterns and their correlation with the prognosis. It is essential to evaluate reactivity in this patients, given that this seems to be the most relevant data when estimating a prognosis. doi:10.1016/j.clinph.2018.04.386
S27. Outcome prediction in postanoxic coma with deep learning—Jeannette Hofmeijer, Barry J. Ruijter, Albertus Beishuizen, Frank H. Bosch, Michel J. van Putten, Marleen C. TjepkemaCloostermans * (Netherlands) ⇑
Presenting author.
Introduction: Visual assessment of the electroencephalogram (EEG) by experienced clinical neurophysiologists allows reliable outcome prediction in up to half of all comatose patients after cardiac arrest. We hypothesize that deep neural networks can achieve similar or better performance, while being objective and consistent. Methods: In a prospective cohort study, continuous EEG recordings from comatose patients after cardiac arrest were collected from the intensive care units of two large teaching hospitals. Functional outcome at six months was assessed using the Cerebral Performance Category scale (CPC), dichotomized as good (CPC 1–2) or poor (CPC 3–5). Five-minute artifact-free EEG epochs at 12 and 24 h after cardiac arrest were partitioned into 10 s epochs. We trained a convolutional neural network, using the raw EEG epochs and outcome labels as inputs to predict outcome using data from 80% of the patients. Validation was performed in the remaining 20%. The probability of recovery to good neurological outcome was quantified for each individual patient. Analyses of diagnostic accuracy included receiver operating characteristics and calculation of predictive values at 12 and 24 h. Results: Four hundred and fifty-six patients were included, resulting in 306 and 439 EEGs epochs at 12 and 24 h, respectively. Outcome prediction was most accurate at 12 h, with an area under the ROC curve (AUC) of 0.89 versus 0.81 at 24 h. Poor outcome could be predicted at 12 h with a sensitivity of 62% (95% confidence interval (CI): 45–78%) at false positive rate (FPR) of 0% (CI: 0–14%); good outcome could be predicted at 12 h with a sensitivity of 50% (CI: 29– 71%) at a FPR of 5% (CI: 1–18%). Conclusion: Deep learning of raw EEG signals outperforms any previously reported outcome predictor of coma after cardiac arrest, including visual assessment by trained EEG expert. Our approach offers the potential for objective and real-time insight in the prognosis of neurological outcome on a continuous scale, and can provide low-cost expertise at the bedside. doi:10.1016/j.clinph.2018.04.387
S28. Survival in patients admitted in an intensive care unit according to electroencephalographic patterns—Mónica B. Perassolo *, Rita L. Aguirre (Argentina) ⇑
Presenting author.
Introduction: The American Society of Neurophysiology implemented a standardized classification (ACNS Standardized) for the evaluation of cerebral electrical activity in critical patients. The interpretation of electroencephalogram (EEG) findings and clinical correlation is still in debate. AIM: To compare survival according to EEG periodic and not periodic pattern in patients hospitalized in an intensive care unit. Methods: Retrospective cohort of patients over 16 years, in coma state, hospitalized consecutively at the intensive care unit (ICU) in a tertiary care hospital in Buenos Aires, Argentina, from 2014 to 2017. We included all patients with at least one 60 min EEG performed at the ICU, registered according to the International System 10/20. We excluded cases with extra-axial compression injuries. We used the ACNS Standardized guidelines (v.2012), Glasgow Outcome Scale (GOS) and Charlson’s comorbidity index (CCI). We
Abstracts / Clinical Neurophysiology 129 (2018) e142–e212
describe the population according to a periodic pattern (PP) and not periodic (NoPP), and compared characteristics between them. We estimate survival during hospitalization at ICU using the Kaplan– Meier method and compared survival between groups with a log rank test. Results: We included 60 patients, mean age was 57 years (SD 18), 41.7% (25) were female. The median stay in ICU was 28 days (IQR 11.5-48). Thirty percent (12) were classified as PP and 70% (48) as NoPP. Comparing baseline characteristics between groups PP vs NoPP, female proportion was (72.2% vs 28.6%; p = 0.01), age (66.1 vs 56.5 years; p = 0.23), CCI (1.5 vs 1; p = 0.58), etiology (intra-axial compressive injuries 11.1% vs destructive injuries 19%; p = 0.46) and time from ICU admission to first EEG (3 vs 4; p = 0.81), respectively. Survival in ICU was for PP vs NoPP was 61.29% (CI95% 33.3– 80.4) vs 79.4% (CI95% 61.6–89.6) p = 0.11, respectively. Functional prognostic at discharge measured as GOS 6 2 was 50% (9) and 38.1% (16) p = 0.41 for PP vs NoPP. Conclusion: A lower in hospital survival was observed in patients admitted to the ICU with a periodic electroencephalographic pattern and a worse functional prognosis compared with patients with nonperiodic pattern. Although this difference is not statistically significant, due to the small sample, we question if pattern detection can define clinical prognosis and mortality in patients at the intensive care unit. doi:10.1016/j.clinph.2018.04.388
S29. rTMS application in disorders of consciousness—Alexandra Poydasheva *, Liudmila Legostaeva, Elizaveta Mochalova, Elena Kremneva, Dmitri Sinitsyn, Dmitri Sergeev, Natalia Suponeva, Julia Ryabinkina, Michael Piradov (Russian Federation) ⇑
Presenting author.
Introduction: There is an unmet need in effective neurorehabilitation methods in chronic disorders of consciousness (DOC). Noninvasive brain stimulation, such as navigated rTMS, is a perspective tool for modulation of the cerebral networks activity in such patients, and resting FMRI, that allows estimating the neural networks activation and interactions, may indicate the target for precise stimulation. Patients with severe brain damage after anoxia or trauma who survived coma, show selective activation of the default mode network (DMN), particularly, gyrus angularis, as the level of consciousness increases. Here, we studied effects of high-frequency navigated rTMS on gyrus angularis as a new approach for the chronic DOC rehabilitation. Methods: We included 10 patients with post-anoxic VS (median age 39.3, mean CRS-R score 5.1); 8 patients with post-anoxic MCS (median age 45.8, mean CRS-R score 14.4); 4 patients with traumatic VS (median age 22.3, mean CRS-R 5.8), and 5 traumatic MCS patients (median age 45.8, mean CRS-R 14.4). EEG revealed no seizure-like electric activity. Individual activation assessed by resting fMRI represented DMN activation including left gyrus angularis area in MCS patients, with no activation of DMN in VS patients. Against the background of standard rehabilitation program (motomed letto IIassisted mechanical therapy, massage, passive joints movements) we provided high-frequency rTMS on the gyrus angularis (10 sessions of stimulation with 20 Hz, 2400 stimulus 90% MT). Consciousness level was assessed with CRS-R scale by the same independent rater before and after stimulation course. Results: CRS-R score increased in the patients with the residual signs of consciousness behavior (MCS). Median increase in CRS-R score after neurorehabilitation course was 2 points. However, we found no change in clinical assessment in the VS cases. No side
e153
effects of the rTMS were observed. Correlation of CRS-r score in permanent disorders of consciousness before and after rTMS course on gyrus angularis. Conclusion: The course of the high-frequency TMS with navigation on gyrus angularis is a potentially effective method of rehabilitation in permanent disorders of consciousness. We obtained clinical effect in states of the minimal signs of consciousness, but not in VS. These results are advisable to continue researches in studies of this new protocol’s effectiveness. The study is supported by Russian Science Foundation grant No. 16-15-00274. doi:10.1016/j.clinph.2018.04.389
S30. Immediate or retarded nerve repair—Clara Nevado *, Juan Pablo Aguado, Antonia Garcia (Spain) ⇑
Presenting author.
Introduction: We presented two cases with complete ulnar nerve section at the very same level, antebrachial region, below branches to flexor digitorum profundus, one with immediate repair and the other with delay repair of about three months. Methods: The delay repair and the immediate repair nerves were at the same month, we make them an EMG at eight weeks from repair and every four weeks until reinnervation took place (motor units seen at abductor digiti minimi). Also echography was done to ensure cubital growing. Age was similar for boths patients, gender: one man (delay) other woman (immediate). Rehabilitation techniques were the same for all of them. Also de the surgeon was the same in all two. Results: Time for reinnervation at the immediate repair was at nine months after the epineural end-to-end repair. Time for reinnervation at the delay repair was five months after a sural nerve graft was used ( eight months after ulnar lesion). Of the two patients the delay repair has had better reinnervation (force 3/5) while the immediate repair ended with 2/5 force and also an ulnar neuroma was seen and removed, months after the nerve reached abductor digiti minimi. Conclusion: As we observed in these particular cases, time is more or less the same in both cases regardless of the technique to repair nerve, probably first is the inflammation phase plus wallerian degeneration, so useful reinervation takes place later, so probably delay repair is not as usefulness as it has been proposed, if it is doing in the right time, after inflammation phase has ended probably avoiding neuroma formation and less endoneural fibrosis, and also we need to search for others ways to avoid inflammation after nerve section to elevate prognosis. doi:10.1016/j.clinph.2018.04.390
S31. Guillain–Barré syndrome outcome at Cipto Mangunkusumo Hospital Jakarta Indonesia—Ahmad Y. Safri *, Ramdinal Avisenna, Luh Ari Indrawati, Fitri Octaviana, Manfaluthy Hakim (Indonesia) ⇑
Presenting author.
Introduction: Erasmus GBS Outcome Score (EGOS) is a model to predict the outcome of patients after GBS. EGOS studies were conducted in well developed countries, which have different patient characteristics and medical facility than in the middle-income country like Indonesia. In the middle-income country, the prognosis