ICU Clinical Correlates
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Questions and Answers

What is a characteristic feature of triphasic waves?

  • Each phase is longer than the preceding (correct)
  • Always suppressed by benzodiazepines
  • Each phase is shorter than the preceding
  • Occur only in anoxic brain injury

    • What is the typical frequency of Frontally Predominant Intermittent Rhythmic Delta Activity (FIRDA)?

  • 3-3.5 Hz
  • 4-4.5 Hz
  • 2-2.5 Hz (correct)
  • 1-1.5 Hz

    • What percentage of patients undergoing cEEG monitoring showed Stimulus Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDS)?

  • 22%
  • 33% (correct)
  • 10%
  • 50%

    • What is a critical question to ask when evaluating EEG patterns?

    <p>Are these discharges causing neuronal damage?</p> Signup and view all the answers

    What is a common association of Frontally Predominant Intermittent Rhythmic Delta Activity (FIRDA)?

    <p>Subcortical or brainstem damage</p> Signup and view all the answers

    What is a characteristic of triphasic waves that distinguishes them from seizures?

    <p>Responds to benzodiazepines</p> Signup and view all the answers

    What is the significance of Stimulus Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDS) in patient care?

    <p>Associated with focal or ictal appearing discharges</p> Signup and view all the answers

    What is a limitation of EEG in evaluating patients with seizures?

    <p>EEG cannot differentiate between status epilepticus and encephalopathy</p> Signup and view all the answers

    What is a common etiology of Frontally Predominant Intermittent Rhythmic Delta Activity (FIRDA)?

    <p>Toxic-metabolic disturbances</p> Signup and view all the answers

    What is the percentage of patients with poor outcome in the study of 116 patients who underwent cEEG and were assessed with modified Rankin Scale at 3 months?

    <p>69%</p> Signup and view all the answers

    Which of the following is an independent predictor of poor outcome in patients with subarachnoid hemorrhage (SAH)?

    <p>Absence of sleep architecture</p> Signup and view all the answers

    What is the odds ratio of poor outcome in patients with SAH who have any periodic discharges (PEDs)?

    <p>9.0</p> Signup and view all the answers

    What percentage of management decisions were influenced by cEEG monitoring in the study of 73 patients?

    <p>82%</p> Signup and view all the answers

    What is the most common management change made as a result of cEEG monitoring?

    <p>Initiation or change of antiepileptic drugs (AEDs)</p> Signup and view all the answers

    What is the minimum duration of a pattern required to meet the criteria for non-convulsive seizure (NCSE)?

    <p>10 seconds</p> Signup and view all the answers

    What is the frequency of repetitive spikes or sharp waves required to meet the criteria for NCSE?

    <p>3 Hz</p> Signup and view all the answers

    What is the significance of triphasic waves in the context of NCSE?

    <p>They can be abolished by administration of benzodiazepines</p> Signup and view all the answers

    What is the term for the spectrum of cerebral activity that includes monomorphic, generalized periodic discharges (GPDs), low-voltage delta, and burst suppression?

    <p>Spectrum of cerebral activity</p> Signup and view all the answers

    What is the term for the type of discharge that is characterized by a rhythmic, localized, and evolving pattern?

    <p>Lateralized periodic discharges (LPDs)</p> Signup and view all the answers

    What is a major concern in a patient with refractory status epilepticus being treated with multiple antiepileptic drugs?

    <p>Hepatotoxicity</p> Signup and view all the answers

    What is the primary goal of managing a patient with status epilepticus?

    <p>Preventing increase in ICP</p> Signup and view all the answers

    What is the characteristic of a monomorphic EEG pattern?

    <p>Repetitive and stereotyped waveforms</p> Signup and view all the answers

    What is the significance of PLEDs in a patient with seizures?

    <p>They are associated with acute infarct, infection, or hematoma</p> Signup and view all the answers

    What is the typical outcome of patients with GPEDs?

    <p>Nearly 100% mortality</p> Signup and view all the answers

    What is the significance of a triphasic wave pattern on EEG?

    <p>It is a variant of GPEDs</p> Signup and view all the answers

    What is the significance of SIRPIDs on EEG?

    <p>They are associated with acute infarct or infection</p> Signup and view all the answers

    What is the primary goal of cerebral activity monitoring in a patient with status epilepticus?

    <p>Detecting seizures</p> Signup and view all the answers

    What is the characteristic of LPDs with a high frequency?

    <p>They are a sign of ictal activity</p> Signup and view all the answers

    What is the significance of a burst-suppression pattern on EEG?

    <p>It is a sign of neuronal injury</p> Signup and view all the answers

    What is the primary reason for continuous EEG monitoring in the NICU?

    <p>To detect subclinical seizures</p> Signup and view all the answers

    According to DeLorenzo's study, what percentage of patients had electrographic seizures after GCSE?

    <p>32%</p> Signup and view all the answers

    What is the level of evidence for absent pupil response, corneals, and motor response at 3 days as predictors of outcome in comatose survivors of cardiac arrest?

    <p>Level A</p> Signup and view all the answers

    What percentage of patients with NCSE had a mortality rate independent of etiology?

    <p>36%</p> Signup and view all the answers

    What is the primary goal of EEG monitoring in the ICU?

    <p>To detect seizures</p> Signup and view all the answers

    According to Vespa's study, what percentage of patients with TBI had NCS detected by cEEG?

    <p>22%</p> Signup and view all the answers

    What is the term for the slowing of EEG activity during a seizure?

    <p>Ictal discharge</p> Signup and view all the answers

    What is the definition of non-convulsive status epilepticus (NCSE)?

    <p>A seizure that is not accompanied by convulsive movements</p> Signup and view all the answers

    According to the AAN Practice Parameter, what is the level of evidence for bilaterally absent cortical responses on SSEPs at 3 days as predictors of outcome in comatose survivors of cardiac arrest?

    <p>Level B</p> Signup and view all the answers

    What is the primary benefit of continuous EEG monitoring in terms of seizure detection?

    <p>It allows for the detection of seizures that are not clinically apparent</p> Signup and view all the answers

    Study Notes

    Triphasic Waves

    • High amplitude, positive discharge
    • Each phase longer than the preceding
    • Frontally predominant +/- A-P lag
    • Associated with hepatic or renal encephalopathy and anoxia
    • Can be suppressed with benzodiazepines, but this does not prove the pattern is a seizure

    Frontally Predominant Intermittent Rhythmic Delta Activity (FIRDA)

    • High amplitude, bisynchronous slow waves
    • Typical frequency of 2-2.5 Hz
    • May be abolished by alerting or eye opening
    • Often seen with triphasic waves
    • Usually implies distal, subcortical or brainstem damage (projected rhythm)
    • Typically seen in toxic-metabolic disturbances
    • May be seen with large midline structural lesions or increased ICP with herniation

    Stimulus Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDS)

    • 22% of patients undergoing cEEG (33/150)
    • Includes PLEDs, GPEDs, triphasics, focal or generalized ictal patterns
    • 50% experienced clinical or subclinical seizures during hospitalization
    • 33% in status epilepticus at some point
    • Associated with focal or ictal appearing discharges

    Periodic Patterns

    • Distinction between ictal, interictal, and not ictal is often not clear
    • EEG alone can fail to clearly differentiate status from encephalopathy
    • Critical questions:
      • Do these discharges cause neuronal damage or neurological consequences?
      • Do they have prognostic significance?
      • Are they treatable, and will suppressing them improve outcome?

    cEEG Findings Predictive of Outcome in SAH

    • 116 patients underwent cEEG and were assessed with modified Rankin Scale at 3 months
    • Overall poor outcome in 69%
    • Independent predictors of poor outcome:
      • Any periodic discharges (PEDs) - 90% vs. 63%, OR 9.0
      • Absence of sleep architecture - 80% vs. 47%, OR 4.3
      • Absence of reactivity - 100%
      • GPEDs or BiPLEDs - 100%
      • NCSE in first 24 hours - 100%

    cEEG Influences Medical Decision Making

    • 73 patients undergoing cEEG
    • Decisive management changes in 51% and contributing management changes in 31%
    • Most common management changes:
      • Initiate or change AED
      • Emergent CT scan

    Spectrum of Cerebral Activity

    • Probably not ictal: monomorphic delta, FIRDA, SIRPIDs
    • Interictal: LPDs, GPEDs, triphasics
    • Ictal: LPDs+, rhythmic spikes and waves, clinical correlates

    Criteria for Non-Convulsive Seizure

    • Any pattern >10 seconds and one of the following:
      • Repetitive spikes or sharp waves at least 3 Hz
      • Rhythmic discharges >1 Hz and unequivocal evolution in frequency, morphology, location
      • Repetitive spike or sharp waves < 3 Hz AND significant clinical improvement and appearance of normal EEG pattern after administration of rapid-acting AED

    ICU Clinical Correlates

    • EEG patterns in the critically ill:
      • Seizures
      • Periodic patterns
      • Background patterns
      • Artifacts

    Why Continuous EEG?

    • Detect subclinical seizures
    • Characterize spells or movements
    • Monitor burst-suppression/Assess sedation level
    • Prognostic information
    • Detect focal or diffuse ischemia

    Mortality of NCS/NCSE Independent of Etiology

    • Electrographic seizures after GCSE:
      • DeLorenzo ‘98: 32% NCS, 51% NCSE
      • Jaitly ‘97: 25% ictal discharges, 41% slowing
    • Time to diagnosis - Young ‘96: 36%
    • Duration - Young ‘96: 75%

    Prognosis-AAN Practice Parameter

    • Review predictors of outcome in comatose survivors of cardiac arrest 1966-2006
    • Level A: absent pupil response, corneals, motor response at 3 days
    • Level B: bilaterally absent cortical responses on SSEPs at 3 days or myoclonic status epilepticus
    • Level C: EEG suppression, burst-suppression, or GPEDs

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    Related Documents

    ICU Clinical Correlates - EEG Patterns in the Critically Ill PDF

    Description

    This quiz covers EEG patterns associated with hepatic or renal encephalopathy, including triphasic waves and frontally predominant intermittent rhythmic delta activity (FIRDA).

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