continuous eeg is superior - mkon...continuous eeg is superior eeg monitoring during coma after...
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CONTINUOUS EEG IS SUPERIOREEG MONITORING DURING COMA AFTER CARDIAC ARREST
JEANNETTE HOFMEIJER, MD PHD
Epilepsy detection
Outcome prediction
Requirements
EEG features
EEG AFTER CARDIAC ARREST
100% specificity for poor outcome prediction
High specificity for good outcome prediction
Background pattern
Reactivity
REACTIVITYBACKGROUND PATTERN
POOR OUTCOME PREDICTION
REACTIVITYBACKGROUND PATTERN
N = 1175
False positives = 0
Clear definitions
POOR OUTCOME PREDICTION
SUPPRESSIONIDENTICAL BURSTS-
SUPPRESSION GPD-SUPPRESSION
REACTIVITY
N = 1131
False positives = 45
Moderate definitions
BACKGROUND PATTERN
N = 1175
False positives = 0
Clear definitions
POOR OUTCOME PREDICTION
SUPPRESSIONIDENTICAL BURSTS-
SUPPRESSION GPD-SUPPRESSION
TP FN FP TN total
<12h 20 2 12 16 50
12-24h 39 8 16 45 108
24-48h 33 12 15 25 85
>48h 12 5 1 5 23
All time points 51 19 14 65 149
ABSENT EEG REACTIVITYHIGH FALSE POSITIVE RATE FOR POOR OUTCOME PREDICTION
Admiraal et al. Annals of Neurology (accepted)
EVOLUTION OF THE EEGFAVORABLE OR UNFAVORABLE
5h 12h 24h
Sondag et al. Crit Care 2017
Hofmeijer et al. Neurology 2015
Sivaraju et al. Int Care Med 2015
THE EVIDENCE
Ruijter et al. Annals of Neurology (accepted)
Identify more patients with poor or good outcome
Greater reliability of EEG conclusions
Detection of epilepsy
Future of brain monitoring
WHY CONTINUOUS EEG?
Identify more patients with poor or good outcome
Greater reliability of EEG conclusions
Detection of epilepsy
Future of brain monitoring
WHY CONTINUOUS EEG?
RESULTSPREDICTIVE VALUES FOR POOR OUTCOME
Ruijter et al. Ann Neurol (accepted)
RESULTSPREDICTIVE VALUES FOR POOR OUTCOME
>50% outside
office hours
Ruijter et al. Ann Neurol (accepted)
YIELD OF REPEATED MEASUREMENTSRELIABLE PROGNOSIS IN MORE PATIENTS
YIELD OF REPEATED MEASUREMENTSRELIABLE PROGNOSIS IN MORE PATIENTS
Identify more patients with poor or good outcome
Greater reliability of EEG conclusions
Detection of epilepsy
Future of brain monitoring
WHY CONTINUOUS EEG?
YIELD OF REPEATED MEASUREMENTSDECREASED UNCERTAINTY
12h 18h 24h
24h 30h 36h
Identify more patients with poor or good outcome
Greater reliability of EEG conclusions
Detection of epilepsy
Future of brain monitoring
WHY CONTINUOUS EEG?
Electrographic seizures / status epilepticus: 10-20%
Non-convulsive ‘seizures’: 10-15%
YIELD OF CONTINUOUS MONITORINGDETECTION OF ELECTROGRAPHIC SEIZURES
Ruijter et al. Trials 2014
Knight et al. Epoilpesy Res 2013
Rittenberger et al. Neurocrit care 2012
Rossetti & Lowenstein. Lancet Neurol 2011
Identify more patients with poor or good outcome
Greater reliability of EEG conclusions
Detection of epilepsy
Future of brain monitoring
WHY CONTINUOUS EEG?
FUTURE OF BRAIN MONITORINGBEDSIDE COMPUTER ASSISTED INTERPRETATION
Tjepkema-Cloostermans et al. Crit Care Med 2017
Nagaraj et al. Clin Neurophysiol 2018
FUTURE OF BRAIN MONITORINGBEDSIDE COMPUTER ASSISTED INTERPRETATION
Tjepkema-Cloostermans et al. Crit Care Med 2017
Nagaraj et al. Clin Neurophysiol 2018
25%
50% uncertainty
25%
Hofmeijer et al. Neurology 2015
Ruijter et al. Ann Neurol (accepted)
Nagaraj et al. Clin Neurophysiol 2018
25%
50% uncertainty
25%
+
27.5%
45%
27.5%
25%
50% uncertainty
25%
27.5%
45%
27.5%
Tjepkema et al. Crit Care Med (accepted)
+
30%
40%
30%
WHY NOT CONTINUOUS EEG?UNJUSTIFIED CONSERVATISM
cEEG Móre reliable predictions in móre patients.
For epilepsy detection cEEG is obligate
Predictive values improve by bedside, computer assisted analysis
Arguments to withhold cEEG are based on conservatism
CONCLUSIONCOMA AFTER CARDIAC ARREST