Nonconvulsive Seizures Research Articles

Time is Brain: Detection of Nonconvulsive Seizures and Status Epilepticus During Acute Stroke Evaluation Using Point-of-Care Electroencephalography.

Seizures are both a common mimic and a potential complication of acute stroke. Although EEG can be helpful to evaluate this differential diagnosis, conventional EEG infrastructure is resource-intensive and unable to provide timely monitoring to match the emergent context of a stroke code. We aimed to evaluate the real-world use and utility of a point-of-care EEG device as an adjunct to acute stroke evaluation. We performed a retrospective observational cohort study at a tertiary care community teaching hospital by identifying patients who underwent point-of-care EEG monitoring using Rapid Response EEG system (Ceribell Inc., Sunnyvale, CA) during stroke code evaluation of acute neurological deficits during the study period from January 1, 2020 to December 31, 2020. We assessed the frequency of seizures and highly epileptiform patterns among patients with either confirmed strokes or stroke mimics. Point-of-care EEG monitoring was used in the wake of a stroke code in 70 patients. Of these, neuroimaging and clinical information resulted in a diagnosis of stroke in 38 patients (28 ischemic, 6 hemorrhagic, 4 transient ischemic attack; median NIHSS score of 6.5 [IQR 2.0-12.0]) and absence of any stroke in 32 patients. Point-of-care EEG detected seizures and highly epileptiform patterns in 6 (15.8%) stroke patients and 11 (34.4%) stroke-mimic patients, including 2 patients with persistent expressive aphasia due to repeated focal seizures. Point-of-care EEG has utility for detecting nonconvulsive seizures in patients undergoing acute stroke evaluations.

A Mouse Model of Temporal Lobe Contusion.

Trauma to the brain can induce a contusion characterized by a discrete intracerebral or diffuse interstitial hemorrhage. In humans, "computed tomography-positive," that is, hemorrhagic, temporal lobe contusions (tlCont) have unique sequelae. TlCont confers significantly increased odds for moderate or worse disability and the inability to return to baseline work capacity compared to intra-axial injuries in other locations. Patients with tlCont are at elevated risks of memory dysfunction, anxiety, and post-traumatic epilepsy due to involvement of neuroanatomical structures unique to the temporal lobe including the amygdala, hippocampus, and ento-/perirhinal cortex. Because of the relative inaccessibility of the temporal lobe in rodents, no preclinical model of tlCont has been described, impeding progress in elucidating the specific pathophysiology unique to tlCont. Here, we present a minimally invasive mouse model of tlCont with the contusion characterized by a traumatic interstitial hemorrhage. Mortality was low and sensorimotor deficits (beam walk, accelerating rotarod) resolved completely within 3-5 days. However, significant deficits in memory (novel object recognition, Morris water maze) and anxiety (elevated plus maze) persisted at 14-35 days and nonconvulsive electroencephalographic seizures and spiking were significantly increased in the hippocampus at 7-21 days. Immunohistochemistry showed widespread astrogliosis and microgliosis, bilateral hippocampal sclerosis, bilateral loss of hippocampal and cortical inhibitory parvalbumin neurons, and evidence of interhemispheric connectional diaschisis involving the fiber bundle in the ventral corpus callosum that connects temporal lobe structures. This model may be useful to advance our understanding of the unique features of tlCont in humans.

Feasibility Assessment of Rapid Response EEG in the Identification of Nonconvulsive Seizures During Military Medical Air Transport.

Traumatic brain injury often requires neurologic care and specialized equipment, not often found downrange. Nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE) occur in up to 30% of patients with moderate or severe traumatic brain injury and is associated with a 39% morbidity and an 18% mortality. It remains difficult to identify at bedside because of the heterogeneous clinical manifestations. The primary diagnostic tool is an electroencephalogram (EEG) which is large, requires an external power source, and requires a specialized technician and neurologist to collect and interpret the data. Rapid response EEG (rr-EEG) is an FDA-approved device that is pocket sized and battery powered and uses a disposable 10-electrode headset. Prior studies have demonstrated the noninferiority of rr-EEG in the identification of NCSE and NCS as compared to conventional EEG in hospitals. An unanswered question is whether rr-EEG could be used in the identification of NCSE and NCS by medics. In conjunction with the Critical Care Air Transport (CCAT) team, a simulation was created and implemented on a CCAT training mission. The simulation team included a neurology resident, who oversaw the simulation, a pulmonary critical care fellow, an intensive care unit nurse, and a respiratory therapy. A survey was provided before and after the simulation. The team was expected to review the rr-EEG to make clinical decisions during ground transport, takeoff, and landing. The neurology resident monitored and recorded the team's ability to distinguish between NCS and a normal EEG. In between, the neurology resident monitored the quality of the EEG for potential interference and loss of quality. The CCAT team was able to efficiently set up the rr-EEG on a patient manikin, correctly identify visual EEG wave forms of a patient in NCS, and utilize the proprietary audio program of a simulated patient in NCS. The team reported that the device was easily set up in the environment, and the data were interpretable despite vibration, aircraft auditory and electrical noise, and the ergonomics of the aircraft medical section. This pilot study has validated a potentially revolutionary technology in medical transport. The rr-EEG technology is measurably user-friendly and will improve patient outcomes. This device and simulation can reduce time to an EEG by hours to days allowing for immediate treatment and intervention, which can significantly reduce morbidity and mortality.

Sensitivity of detecting interictal epileptiform activity using rapid reduced montage EEG

ObjectiveRapid EEG devices (REDs) have demonstrated substantial benefit regarding reduced time to performance of study and diagnosis in cases where urgent EEG is needed to evaluate patients for potentially revealing nonconvulsive status epilepticus and seizures. However, urgent EEG is also important in identifying cases regarding the need for initiation of antiseizure medication as well as triaging the use of continuous EEG monitoring. Some forms of REDs have a reduced montage (RRME) with electrode derivations that are one-half of standard recordings. This could impact spatial resolution and therefore potentially limit recovery of epileptiform abnormalities. MethodsIn this study we evaluated the use of the Ceribell® rapid response EEG system and compared it to conventional video EEG (CvEEG). After applying inclusion and exclusion criteria, a total of 20 subjects were included in our analysis. ResultsRRME was highly sensitive in detecting abundant and periodic discharges (p = 0.013) as well as discharges with a broad spatial distribution on CvEEG (p = 0.039). Sensitivity for detecting less prevalent discharges or those with more restricted spatial distribution was lower. SignificanceGiven the possibility of less frequent and more restricted epileptiform discharges eluding detection on RRME, we propose a protocol for the approach of using RRME and when to consider CvEEG when RRME is negative for epileptiform activity and highlight that urgent CvEEG may still be warranted following RRME.

Rapid Electroencephalography and Artificial Intelligence in the Detection and Management of Nonconvulsive Seizures

Nonconvulsive status epilepticus is a commonly overlooked cause of altered mental status. This study assessed nonconvulsive status epilepticus prevalence in emergency department (ED) patients with acute neurologic presentations using limited electroencephalogram (EEG) coupled with artificial intelligence (AI)-enhanced seizure detection technology. We then compared the accuracy of the AI EEG interpretations to those performed by an epileptologist. In a prospective observational cohort analysis, adult patients with unexplained mental status changes identified by emergency physicians received expedited placement of a limited EEG. Data collected encompassed patient demographics, clinical history, EEG interpretations by the AI algorithm and epileptologists, treatments, and disposition determinations. There were 134 device applications on 132 patients (2 received the device twice) enrolled in the study, but 16 were missing data critical for identification or analysis and 9 did not meet the selection criteria. Of the 108 limited EEGs interpreted by an epileptologist, 69 were abnormal (diffuse slowing, highly epileptiform patterns, or spikes and sharps), 41 were normal, 5 were uninterpretable, and 3 captured episodes of seizure or status epilepticus. Limited EEG AI interpretation detected >90% seizure burden in 2 of 3 cases of seizure or status epilepticus as well as in 2 abnormal EEGs and 1 normal EEG, providing a sensitivity of 66.7% (95% confidence interval 9.4 to 99.2), a specificity of 97.0% (95% confidence interval 91.5 to 99.4), and a disease prevalence of 2.9%. Limited AI-enhanced EEG can detect nonconvulsive status epilepticus in the ED; however, the technology tended to overestimate seizure burden in our cohort. This study found a lower nonconvulsive status epilepticus prevalence compared to prior literature reports.

Subthreshold Cannabidiol Potentiates Levetiracetam in the Kainic Acid Model of Temporal Lobe Epilepsy: A Pilot Study.

Refractoriness to antiseizure medications is still a major concern in the pharmacotherapy of epilepsy. For this reason, we decided to evaluate the combination of levetiracetam and cannabidiol, administered at a subthreshold dose, to limit the possible adverse effects of this phytocannabinoid. We administered levetiracetam (300 mg/kg/day, via osmotic minipumps), cannabidiol (120 mg/kg/day, injected once a day subcutaneously), or their combination for one week in epileptic rats. Saline-treated epileptic rats were the control group. Animals were monitored with video electroencephalography the week before and after the treatment. No changes were found in the controls. Levetiracetam did not significantly reduce the total seizure number or the overall seizure duration. Still, the overall number of seizures (p < 0.001, Duncan's new multiple range test) and their total duration (p < 0.01) increased in the week following treatment withdrawal. Cannabidiol did not change seizures when administered as a single drug. Instead, levetiracetam combined with cannabidiol resulted in a significant reduction in the overall number and duration of seizures (p < 0.05), when comparing values measured during treatment with both pre- and post-treatment values. These findings depended on changes in convulsive seizures, while non-convulsive seizures were stable. These results suggest that cannabidiol determined a remarkable potentiation of levetiracetam antiseizure effects at a subthreshold dose.

Continuous Electroencephalographic Monitoring in Adult ICU Challenges and Potential Solutions: A Scoping Review

Background: Continuous electroencephalographic (cEEG) monitoring is continuous monitoring of brain activity that is often used in the intensive care unit (ICU). Recently, the usage of cEEG has grown in many institutions as it detects non-convulsive seizures better than routine EEG (rEEG). However, due to the aggressive environment of ICU, the application and the prolonged recording is challenging. The objectives of this scoping review are to evaluate the common challenges faced during cEEG in adult ICU and proper solutions for optimal implementation. Methods: A scoping review was conducted using Arksey and O’Malley framework. The included articles contain “continuous EEG in ICU settings” in their titles, written in English, and published between 2010 and 2022. That was by searching the databases: PubMed, Google Scholar, and Summon. Results: 14 articles were included as they meet the criteria of this review. (28.57 %) of the included studies mentioned the challenges regarding staff, (42.85 %) addressed the challenges of electrode application and the alternative techniques in ICU, and (42.85%) discussed the difficulties in interpretation and duration of the recording. Conclusion: Continuous EEG is increasingly recognized as valuable mean of monitoring cerebral function, but it is faced with numerous challenges: the difficult environment of ICU and the type of critical patient admitted requiring the optimal electrode application and maintenance, minimizing artifacts and adequate duration of recording to detect abnormalities, and sufficiently trained personnel including ICU staff, technologist and neurophysiologist to provide the optimal patient care as it is the main goal.

Incidence of seizures in ICU patients with diffuse encephalopathy and its predictors.

Encephalopathy is a diffuse brain dysfunction that results from systemic disorder. Patients with diffuse encephalopathy are at risk of developing clinical and electrographic seizures. The aim of this study is to assess the prevalence of electrographic seizures in a setting of encephalopathy and the clinical and electroencephalogram predictors. We retrospectively reviewed all continuous electroencephalograms done between 2019 and 2022. Continuous electroencephalograms with diffuse encephalopathy were included in the study. A total of 128 patients with diffuse encephalopathy were included in this study. Patients' ages ranged from 18 to 96 years old with a mean age of 55.3 ± 19.2 years old. Nine out of 128 patients had seizures with an incidence of 7%. Sixty-six point six percent were nonconvulsive electrographic seizures. Fourteen point three percent of the female patients with diffuse encephalopathy had seizures as compared to none of the male patients (P = .002). Also, 12% of patients with a history of epilepsy experienced seizures versus 5.8% of patients without this history (P = .049). Among electrographic features, 25% of patients with delta background had seizures versus 2.3% of the other patients (P = .048). Likewise, 90% of patients with periodic discharges developed seizures in comparison with none of the patients without (P = .001). Seizures are seen in 7% of patients with diffuse encephalopathy. Female gender, past history of epilepsy, delta background and periodic discharges are significant predictors of seizure development in patients with diffuse encephalopathy.

Evaluating the Impact of Point-of-Care Electroencephalography on Length of Stay in the Intensive Care Unit: Subanalysis of the SAFER-EEG Trial.

Electroencephalography (EEG) is needed to diagnose nonconvulsive seizures. Prolonged nonconvulsive seizures are associated with neuronal injuries and deleterious clinical outcomes. However, it is uncertain whether the rapid identification of these seizures using point-of-care EEG (POC-EEG) can have a positive impact on clinical outcomes. In a retrospective subanalysis of the recently completed multicenter Seizure Assessment and Forecasting with Efficient Rapid-EEG (SAFER-EEG) trial, we compared intensive care unit (ICU) length of stay (LOS), unfavorable functional outcome (modified Rankin Scale score ≥ 4), and time to EEG between adult patients receiving a US Food and Drug Administration-cleared POC-EEG (Ceribell, Inc.) and those receiving conventional EEG (conv-EEG). Patient records from January 2018 to June 2022 at three different academic centers were reviewed, focusing on EEG timing and clinical outcomes. Propensity score matching was applied using key clinical covariates to control for confounders. Medians and interquartile ranges (IQRs) were calculated for descriptive statistics. Nonparametric tests (Mann-Whitney U-test) were used for the continuous variables, and the χ2 test was used for the proportions. A total of 283 ICU patients (62 conv-EEG, 221 POC-EEG) were included. The two populations were matched using demographic and clinical characteristics. We found that the ICU LOS was significantly shorter in the POC-EEG cohort compared to the conv-EEG cohort (3.9 [IQR 1.9-8.8] vs. 8.0 [IQR 3.0-16.0] days, p = 0.003). Moreover, modified Rankin Scale functional outcomes were also different between the two EEG cohorts (p = 0.047). This study reveals a significant association between early POC-EEG detection of nonconvulsive seizures and decreased ICU LOS. The POC-EEG differed from conv-EEG, demonstrating better functional outcomes compared with the latter in a matched analysis. These findings corroborate previous research advocating the benefit of early diagnosis of nonconvulsive seizure. The causal relationship between the type of EEG and metrics of interest, such as ICU LOS and functional/clinical outcomes, needs to be confirmed in future prospective randomized studies.

Comparison of Continuous Intracortical and Scalp Electroencephalography in Comatose Patients with Acute Brain Injury.

Depth electroencephalography (dEEG) is a recent invasive monitoring technique used in patients with acute brain injury. This study aimed to describe in detail the clinical manifestations of nonconvulsive seizures (NCSzs) with and without a surface EEG correlate, analyze their long-standing effects, and provide data that contribute to understanding the significance of certain scalp EEG patterns observed in critically ill patients. We prospectively enrolled a cohort of 33 adults with severe acute brain injury admitted to the neurological intensive care unit. All of them underwent multimodal invasive monitoring, including dEEG. All patients were scanned on a 3T magnetic resonance imaging scanner at 6months after hospital discharge, and mesial temporal atrophy (MTA) was calculated using a visual scale. In 21 (65.6%) of 32 study participants, highly epileptiform intracortical patterns were observed. A total of 11 (34.3%) patients had electrographic or electroclinical seizures in the dEEG, of whom 8 had both spontaneous and stimulus-induced (SI) seizures, and 3 patients had only spontaneous intracortical seizures. An unequivocal ictal scalp correlate was observed in only 3 (27.2%) of the 11 study participants. SI-NCSzs occurred during nursing care, medical procedures, and family visits. Subtle clinical manifestations, such as restlessness, purposeless stereotyped movements of the upper limbs, ventilation disturbances, jerks, head movements, hyperextension posturing, chewing, and oroalimentary automatisms, occurred during intracortical electroclinical seizures. MTA was detected in 18 (81.8%) of the 22 patients. There were no statistically significant differences between patients with MTA with and without seizures or status epilepticus. Most NCSzs in critically ill comatose patients remain undetectable on scalp EEG. SI-NCSzs frequently occur during nursing care, medical procedures, and family visits. Semiology of NCSzs included ictal minor signs and subtle symptoms, such as breathing pattern changes manifested as patient-ventilator dyssynchrony.

Peripherally-derived LGI1-reactive monoclonal antibodies cause epileptic seizures in vivo.

One striking clinical hallmark in patients with autoantibodies to leucine-rich glioma inactivated 1 (LGI1) is the very frequent focal seizure semiologies, including faciobrachial dystonic seizures (FBDS), in addition to the amnesia. Polyclonal serum IgGs have successfully modelled the cognitive changes in vivo but not seizures. Hence, it remains unclear whether LGI1-autoantibodies are sufficient to cause seizures. We tested this with the molecularly precise monoclonal antibodies directed against LGI1 [LGI1-monoclonal antibodies (mAbs)], derived from patient circulating B cells. These were directed towards both major domains of LGI1, leucine-rich repeat and epitempin repeat, and infused intracerebroventricularly over 7 days into juvenile male Wistar rats using osmotic pumps. Continuous wireless EEG was recorded from a depth electrode placed in hippocampal CA3 plus behavioural tests for memory and hyperexcitability were performed. Following infusion completion (Day 9), post-mortem brain slices were studied for antibody binding and effects on Kv1.1. The LGI1-mAbs bound most strongly in the hippocampal CA3 region and induced a significant reduction in Kv1.1 cluster number in this subfield. By comparison to control-Ab injected rats video-EEG analysis over 9 days revealed convulsive and non-convulsive seizure activity in rats infused with LGI1-mAbs, with a significant number of ictal events. Memory was not impaired in the novel object recognition test. Peripherally-derived human LGI1-mAbs infused into rodent CSF provide strong evidence of direct in vivo epileptogenesis with molecular correlations. These findings fulfill criteria for LGI1-antibodies in seizure causation.

It’s About Time! Timing in Epilepsy Evaluation and Treatment

The 2023 American Epilepsy Society Annual Course “It’s About Time” addressed timing in epilepsy evaluation and treatment with respect to health disparity and vulnerable populations and diagnostic, clinical, and epilepsy surgery evaluation. This comprehensive course included topics on gaps in epilepsy care and optimization of behavioral health for patients with epilepsy. The summary details current knowledge in areas of seizure forecasting and epileptogenesis. Intricacies and controversies over timing were discussed for treatment of nonconvulsive seizures and ictal-interictal patterns, acute symptomatic seizures, neuromodulation versus surgery, and epilepsy surgery in status epilepticus. Timing regarding clinical care in autoimmune-associated epilepsy, developmental and epileptic encephalopathy, and dietary therapy were examined. Additionally, salient topics on using novel biomarkers and collaboration with neuropsychological outcomes were also tackled in this all-encompassing lecture series.

Convulsioni e stato di male epilettico: schema sinottico per l'intervento in emergenza/urgenza - Aggiornamento 2023

The updated revision of the epilepticus status (ES) thera-py poster is addressed to all paediatric emergency work-ers, but not to parents and/or lay people; it does not ad-dress the management of neonatal and nonconvulsive sei-zures. The objective of this poster is to summarize the management and treatment of the child presenting with seizures that can progress to ES.

Very high epilepsy prevalence in rural Southern Rwanda: The underestimated burden of epilepsy in sub-Saharan Africa.

Up to 85% of people living with epilepsy (PwE) reside in low-and middle-income countries. In sub-Saharan Africa, the lifetime prevalence of epilepsy is 16 per 1000 persons. In Northern rural Rwanda, a 47.7 per 1000 prevalence has been reported. As variations in prevalence across geographical areas have been observed, we studied the prevalence in Southern rural Rwanda using the same robust methodology as applied in the North. We conducted a three-stage, cross-sectional, door-to-door survey in two rural villages in Southern Rwanda from June 2022 to April 2023. First, trained enumerators administered the validated Limoges questionnaire for epilepsy screening. Second, neurologists examined the persons who had screened positively to confirm the epilepsy diagnosis. Third, cases with an inconclusive assessment were separately reexamined by two neurologists to reevaluate the diagnosis. Enumerators screened 1745 persons (54.4% female, mean age: 24 ± 19.3 years), of whom 304 (17.4%) screened positive. Epilepsy diagnosis was confirmed in 133 (52.6% female, mean age: 30 ± 18.2 years) and active epilepsy in 130 persons. Lifetime epilepsy prevalence was 76.2 per 1000 (95% CI: 64.2-89.7‰). The highest age-specific rate occurred in the 29-49 age group. No gender-specific differences were noted. In 22.6% of the PwE, only non-convulsive seizures occurred. The treatment gap was 92.2%, including a diagnosis gap of 79.4%. We demonstrated a very high epilepsy prevalence in Southern rural Rwanda, with over 20% of cases having only non-convulsive seizures, which are often underdiagnosed in rural Africa. In line with previous Rwandan reports, we reiterate the high burden of the disease in the country. Geographic variation in prevalence throughout Africa may result from differences in risk and aetiological factors. Case-control studies are underway to understand such differences and propose adapted health policies for epilepsy prevention.

Prevalence of nonconvulsive seizures and nonconvulsive status epilepticus in dogs and cats with a history of cluster seizures: A retrospective study.

Nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE) are frequently observed in human patients. Diagnosis of NCS and NCSE only can be achieved by the use of electroencephalography (EEG). Electroencephalographic monitoring is rare in veterinary medicine and consequently there is limited data on frequency of NCS and NCSE. Determine the prevalence of NCS and NCSE in dogs and cats with a history of cluster seizures. Twenty-six dogs and 12 cats. Retrospective study. Medical records of dogs and cats with cluster seizures were reviewed. Electroencephalography was performed in order to identify electrographic seizure activity after the apparent cessation of convulsive seizure activity. Nonconvulsive seizures were detected in 9 dogs and 2 cats out of the 38 patients (29%). Nonconvulsive status epilepticus was detected in 4 dogs and 2 cats (16%). Five patients had both NCS and NCSE. A decreased level of consciousness was evident in 6/11 patients with NCS, 3/6 also had NCSE. Mortality rate for patients with NCS (73%) and NCSE (67%) was much higher than that for patients with no seizure activity on EEG (27%). Prevalence of NCS and NCSE is high in dogs and cats with a history of cluster seizures. Nonconvulsive seizures and NCSE are difficult to detect clinically and are associated with higher in hospital mortality rates. Results indicate that prompt EEG monitoring should be performed in dogs and cats with cluster seizures.

THE PHENOMENON OF SIMULATING SEIZURES IN EPILEPSY: CASE REPORT

Psychogenic non-epileptic seizures may resemble epileptic ones, but bioelectric activity is not recorded on the electroencephalogram. In some cases, psychogenic non-epileptic seizures and epilepsy are diagnosed simultaneously. The frequency of epilepsy in patients with diagnosed psychogenic non–epileptic seizures is 22%, and the incidence of psychogenic non-epileptic seizures among patients with epilepsy is 12%. The article describes a clinical case of a patient with diagnosed epilepsy, in whom psychogenic non-epileptic seizures were detected simultaneously with epileptic seizures. Polymorphic non-convulsive and convulsive seizures were observed in the clinical presentation. The patient received anti-epileptic therapy in high doses for a long time without significant effect. Convulsive seizures in most cases occurred during the day in crowded places in the presence of people. Most often, the patient managed to attract the attention of others and ask for help. A pathopsychological examination revealed a pronounced sharpening of hysteroid and epileptoid traits with excessive fixation on the state of the patient's health. For the first time in years of being treated by different doctors, the patient admitted during psychotherapy that convulsive seizures that occur with her are "useful". It was advantageous for her to take on the role of a person out of health in order to protect herself from her husband's aggression and get sympathy, feel special, get rid of extra burden at work. The article provides a differential diagnosis between factitious disorder, conversion disorder, simulation and aggravation. It is concluded that convulsive seizures in the patient occurred by the mechanism of a factitious disorder. The following facts speak in favor of this: motivation for this behavior is not clear to others and is of an internal nature, the desire to accept the role of a person out of health, awareness of seizures "usefulness", lack of attention in the family, hysteroid character traits. It is concluded that for the successful treatment of comorbidity conditions of psychogenic non-epileptic seizures and epilepsy, close interaction of a neurologist, a psychiatrist, a psychotherapist and a psychologist is extremely important.

Case Report: Non-convulsive seizure following traumatic brain injury — a significant occurrence that needs to be considered due to potential long-term sequelae

Introduction/background Non convulsive seizures (NCS) following traumatic brain injury (TBI) may remain undiagnosed due to lack of overt clinical manifestation and can have long-term sequelae due to delay in timely treatment. Occurrence of early NCS is known to have subsequent neurologic sequelae due to excitotoxic neuronal injury. Case report This is a case report of a young girl who sustained a TBI due to a motor vehicle accident (MVA) and was admitted with a fluctuating level of consciousness. Her clinical presentation was attributed to TBI; however as her conscious level did not recover, an electroencephalogram (EEG) was requested, which detected non convulsive status epilepticus (NCSE). Anti-seizure medication (ASM) was started. Her follow-up EEG and magnetic resonance imaging (MRI) were suggestive of the potential adverse effects of prolonged NCSE. Conclusion NCS may remain undiagnosed in TBI due to a paucity of overt clinical manifestations. Every patient with TBI and altered consciousness at presentation should be evaluated by EEG immediately, if possible, in the emergency department to avoid long-term sequelae of NCS in such cases.

Safety and Efficacy of Ketamine Without Intubation in the Management of Refractory Seizures: A Case Series.

Continuous infusion ketamine has demonstrated efficacy in the management of refractory seizures yet does not suppress respiratory drive like other continuous infusion anesthetics (CIAs) used for this indication. The aim of this study is to describe the safety and efficacy of ketamine infusions in patients with refractory seizure without intubation. We analyzed a retrospective cohort of adult patients who were not intubated at the time of initiation of a ketamine infusion for refractory seizures. Seizure onset was determined to be the first clinical seizure or nonconvulsive seizure reported on electroencephalography (EEG) or the start time of EEG for patients with seizures at EEG initiation. Responders were defined as patients with resolution of seizures within 24h of initiation without the need for intubation or an additional CIA. A total of 28 patients were analyzed (median age 62years, 64.3% female, 82.1% African American, 82.1% with structural seizure etiology, and 85.7% focal seizures). Of patients, 78.5% received an initial bolus averaging 0.9mg/kg, and the majority (89.3%) were initiated on an infusion at 10μg/kg/minute; median duration was 39.8h. Maximum infusion rates were 10μg/kg/minute in 16 patients, 20μg/kg/minute in seven patients, and 30μg/kg/minute in five patients. Of patients, 71.4% were assessed to be ketamine responders; six of the eight nonresponders required intubation and an additional CIA. Responders were 80% more likely to have received ketamine 5 or more hours earlier than nonresponders. Hypotension (systolic blood pressure < 90mmHg) occurred in 31.8% of patients receiving only ketamine, which did not correlate with duration or maximum dose of ketamine; hypertension (systolic blood pressure > 180mmHg) occurred in 39.3%. Ketamine represents a safe and effective treatment option for refractory seizures and has potential to reduce morbidity associated with intubation in a carefully selected patient population. Early initiation may increase the likelihood of success.

Rapid-Response Electroencephalography in Seizure Diagnosis and Patient Care: Lessons From a Community Hospital.

BACKGROUND: Nonconvulsive seizures are a major source of in-hospital morbidity and a cause of unexplained encephalopathy in critically ill patients. Electroencephalography (EEG) is essential to confirm nonconvulsive seizures and can guide patient-specific workup, treatment, and prognostication. In a 208-bed community hospital, EEG services were limited to 1 part-time EEG technician and 1 EEG machine shared between inpatient and outpatient settings. Its use was restricted to typical business hours. A nursing-led quality improvement (QI) project endeavored to enhance access to EEG by introducing a point-of-care rapid-response EEG program. METHODS: For this project, a multidisciplinary protocol was developed to deploy a Food and Drug Administration-cleared, point-of-care rapid-response EEG platform (Ceribell Inc) in a community hospital's emergency department and inpatient units to streamline neurodiagnostic workups. This QI project compared EEG volume, study location, time-to-EEG, number of cases with seizures captured on EEG, and hospital-level financial metrics of diagnosis-related group reimbursements and length of stay for the 6 months before (pre-QI, using conventional EEG) and 6 months after implementing the rapid-response protocol (post-QI). RESULTS: Electroencephalography volume increased from 35 studies pre-QI to 115 post-QI (3.29-fold increase), whereas the median time from EEG order to EEG start decreased 7.6-fold (74 [34-187] minutes post-QI vs 562 [321-1034] minutes pre-QI). Point-of-care EEG was also associated with more confirmed seizure diagnoses compared with conventional EEG (27/115 post-QI vs 0/35 pre-QI). This resulted in additional diagnosis-related group reimbursements and hospital revenue. Availability of point-of-care EEG was also associated with a shorter median length of stay. CONCLUSION: A nurse-led, rapid-response EEG protocol at a community hospital resulted in significant improvements in EEG accessibility and seizure diagnosis with hospital-level financial benefits. By expanding access to EEG, confirming nonconvulsive seizures, and increasing care efficiency, rapid-response EEG protocols can enhance patient care.

Point-of-care electroencephalography enables rapid evaluation and management of non-convulsive seizures and status epilepticus in the emergency department.

To describe our institutional experience with point-of-care electroencephalography (pocEEG) and its impact on the evaluation/management of suspected non-convulsive seizures in the emergency department (ED). We retrospectively identified 157 adults who underwent pocEEG monitoring in our community hospital ED in 1 year. We calculated the time to obtain pocEEG in the ED (door-to-EEG time) and examined the impact of pocEEG findings (categorized as seizure, highly epileptiform patterns, slowing, or normal activity) on antiseizure medication treatment. PocEEG revealed seizures (14%, n=22), highly epileptiform patterns (22%, n=34), slowing (44%, n=69), and normal activity (20%, n=32). The median door-to-EEG time (from initial ED evaluation to pocEEG monitoring) was only 1.2hours (interquartile range 0.1-2.1) even though 55% of studies were performed after-hours (5 pm-9 am). Most patients were admitted (54% to the intensive care unit, 41% to floor). Antiseizure medication treatment occurred pre-pocEEG in 93 patients (59%) and post-pocEEG in 88 patients (56%). By reviewing the relationship between pocEEG monitoring and antiseizure medication management, we found a significant association between pocEEG findings and changes in management(P<0.001). Treatment escalation occurred more frequently in patients with epileptiform activity (seizures or highly epileptiform patterns, 52%) than patients with non-epileptiform activity (normal or slow, 25%, P<0.001), and avoidance of treatment escalation occurred more frequently in patients with normal or slow activity (27%) than patients with seizures or highly epileptiform patterns (2%, P<0.001). Our study, the largest to date describing the real-world use of pocEEG in emergency medicine, found that rapid EEG acquisition in the ED was feasible in a community hospital and significantly affected the management of suspected non-convulsive seizures.