Abstract
BackgroundEEG-based prognostication studies in intensive care units often rely on a standard 21-electrode montage (stdEEG) requiring substantial human, technical, and financial resources. We here evaluate whether a simplified 4-frontal electrode montage (4-frontEEG) can detect EEG patterns associated with poor outcomes in adult patients under veno-arterial extracorporeal membrane oxygenation (VA-ECMO).MethodsWe conducted a reanalysis of EEG data from a prospective cohort on 118 adult patients under VA-ECMO, in whom EEG was performed on admission to intensive care. EEG patterns of interest included background rhythm, discontinuity, reactivity, and the Synek’s score. They were all reassessed by an intensivist on a 4-frontEEG montage, whose analysis was then compared to an expert’s interpretation made on stdEEG recordings. The main outcome measure was the degree of correlation between 4-frontEEG and stdEEG montages to identify EEG patterns of interest. The performance of the Synek scores calculated on 4-frontEEG and stdEEG montage to predict outcomes (i.e., 28-day mortality and 90-day Rankin score {ge {4}}) was investigated in a secondary exploratory analysis.ResultsThe detection of EEG patterns using 4-frontEEG was statistically similar to that of stdEEG for background rhythm (Spearman rank test, ρ = 0.66, p < 0.001), discontinuity (Cohen’s kappa, kappa = 0.955), reactivity (kappa = 0.739) and the Synek’s score (ρ = 0.794, p < 0.001). Using the Synek classification, we found similar performances between 4-frontEEG and stdEEG montages in predicting 28-day mortality (AUC 4-frontEEG 0.71, AUC stdEEG 0.68) and for 90-day poor neurologic outcome (AUC 4-frontEEG 0.71, AUC stdEEG 0.66). An exploratory analysis confirmed that the Synek scores determined by 4 or 21 electrodes were independently associated with 28-day mortality and poor 90-day functional outcome.ConclusionIn adult patients under VA-ECMO, a simplified 4-frontal electrode EEG montage interpreted by an intensivist, detected common EEG patterns associated with poor outcomes, with a performance similar to that of a standard EEG montage interpreted by expert neurophysiologists. This simplified montage could be implemented as part of a multimodal evaluation for bedside prognostication.
Highlights
Electroencephalography (EEG) is an almost centuryold, non-invasive method deployed for electrophysiological brain investigations
We aimed to evaluate whether a simplified 4-frontal electrode montage (4-frontEEG) could detect EEG patterns associated with poor outcomes in adult patients under veno-arterial extracorporeal membrane oxygenation (VA-ECMO), as compared to interpretation made on standard 21-electrode mon‐ tage (stdEEG) recordings
We found that the stdEEG Synek score was associated with 28-day mortality (Fig. 3, areas under curves (AUC) = 0.68, accuracy: 64%, p < 0.001, sensitivity = 0.45 and specificity = 0.84) and with a 90-day Rankin score ≥ 4 (AUC = 0.66, accuracy: 66%, p = 0.004, sensitivity = 0.30 and specificity = 0.85)
Summary
Electroencephalography (EEG) is an almost centuryold, non-invasive method deployed for electrophysiological brain investigations. The recent use of the Synek score in other critical conditions, such as cardiac arrest [6, 7], sepsis-associated encephalopathy [3] and traumatic brain injury [8] suggests that the use of such EEG scores could be of interest in adult VA-ECMO patients. The Synek score ranges from 1 to 5, with higher scores indicating more severe encephalopathy mRS: modified Rankin scale; OR: odds ratio; EEG: electroencephalography; 4-frontEEG: 4-electrode montage; stdEEG: 21-electrode montage a The association between each EEG variable (background rhythm, and Synek’s scores on 4-frontEEG and stdEEG) and outcomes (day-28 mortality and day-90 mRS score ≥ 4) were evaluated using logistic regression analyses adjusted for age, pre-ECMO cardiac arrest, and non-neurological SOFA score at time of cannulation identified using the full montage [18,19,20]. For prediction of good outcome, it appears to have added value [14]
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