You are on page 1of 19

Amplitude integrated EEG

beyond the NICU

Ingmar Rosén
Division of Clinical Neurophysiology
Department of Clinical Science Lund
Lund University

•Restoration of EEG background

•Detection of seizure events>> SE


Prior and Maynard

Old CFM in neonatal monitoring

10 days of CFM !

Ingmar Rosen, MD: Jan. 17, 2008 1


Old CFM-problems
• Artefacts (movements,care procedures,
ECG, high frequency ventilation)

• Lack of correllation with the original EEG


signal.

• Neonatal aEEG interpretation became an


art of its own, independent of the vast
EEG-knowledge/experience

CFM/aEEG development

New aEEG/EEG
• Shows the real EEG

• Stores digital EEG, available for review


and reanalysis

• Flexibility – trends, number of


channels, time resolution

New aEEG/EEG monitors by: BrainZ,


Viasys, Olympic, Micromed, Day One

Ingmar Rosen, MD: Jan. 17, 2008 2


Patterns discernable by simplified
aEEG/EEG monitoring

• Pathology of EEG background-prognosis

• Monitoring before-during-after
hypothermia

• Seizure patterns-possibility to treat

Applications of aEEG trend monitoring in


paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus and follow up of
acute treatment

• Detection of rare seizure patterns in immobilized


children

• Useful tool in full video-EEG monitoring

• Contributes to prognosis after severe ishemic


insult/cardiac arrest

aEEG and SE monitoring


• The additional value of aEEG monitoring is
depending upon type and EEG features of
the SE

• An early full EEG is recommended and is


often used for tailoring the monitoring

Ingmar Rosen, MD: Jan. 17, 2008 3


EEG message in SE

High intensity Risk of excitotoxic


seizure pattern injury

Repetitive focal Immediate interference


or generalized with cognition/consciousness
spiking

ESES Deleterious plastic


CSWS effects on brain
Epileptic encephalopathy functional development
of childhood

Progress of generalized convulsive SE


(Treiman)

Start of clinical seizure

Ingmar Rosen, MD: Jan. 17, 2008 4


Continuous generalized seizure pattern

EEG

Seizure pattern arrested by propofol

Continuous EEG

EEG

Seizure pattern arrested by propofol

Burst-Suppression pattern

Ingmar Rosen, MD: Jan. 17, 2008 5


Status epilepticus (AD-2003)
• 4 y girl
• Olfactory neuroblastoma, posterior
fossa+front dx
• Post op unconscious suspected seizures
• Full EEG
• 2 channel aEEG/EEG monitoring

AD-2003

Ingmar Rosen, MD: Jan. 17, 2008 6


AD-2003-mon d1

AD-2003-mon d 9

AD-2003-mon d 9

Ingmar Rosen, MD: Jan. 17, 2008 7


Focal seizures and limited
number of recording channels
How serious is the problem ?

With tailored design sufficient sensitivity is


attained with few recording channels (and
electrodes)

The brain is a volume conductor

3 focal seizures with different locations all appear in one channel aEEG trace

P3-P4

C3-P3

C4-P4
A

Ingmar Rosen, MD: Jan. 17, 2008 8


TN (severe epileptic
encephalopathy)
• Girl born 34+5 w. Pre-eclampsia.
• 6d gen seiz ; Phbarb, Fos-phen, Midazol.
• Seizure free from 10 d
• 2 m foc seiz left eye+ hand + gen ton s
• Repeated seizure periods
• 5 m EEG: Hypsarrythmia. Therapy resistent
• 11m Ketogenic diet with some improvement;
several seizure types

TN 2 m seizure

TN 2 m ii

Ingmar Rosen, MD: Jan. 17, 2008 9


TN 2 m i

TN 11 m

TN 11 m

Ingmar Rosen, MD: Jan. 17, 2008 10


aEEG and SE monitoring
• The additional value of aEEG monitoring is depending
upon type and EEG features of the SE

• An early full EEG is recommended and is often used for


tailoring the monitoring

• Flexibility of channel number, position, and trend mode is


an advantage

• 2 channel (F3-P3; F4-P4) aEEG/EEG recording


recommended after the neonatal period

Green hours

Monitor Final
Acute EEG
tailored Sum up

Red hours

Final
Monitor Monitor
EEG Sum up
standard tailored

Seizure detection (EK-2007)


• 7 m girl with achondroplasia
• Decompressive surgery posterior fossa
• Post op hiccups and apnoeic episodes
• Full EEG: diffuse slowing-no epileptiform
activity
• Seizures ?

Ingmar Rosen, MD: Jan. 17, 2008 11


EK-2007

1
3

EK-2007

Suspected seizures (AG-2003)


• 4 y girl from Kosovo
• Severe perinatal cerebral lesion
( mechonium aspiration reported)
• Severe dystonic CP
• Microcephaly with extensive cortical and white
matter lesions
• EEG: pathological with interictal positive sharp
waves right side
• Frequent attacks of extension –seizures ?

Ingmar Rosen, MD: Jan. 17, 2008 12


AG-2003

AG-2003

AG-2003

Ingmar Rosen, MD: Jan. 17, 2008 13


AG-2003

Video-EEG(HL-2002)
• 5y girl
• Short history of focal epilepsy
• Subtle episodes with absense sometimes
drawling, sometimes subtle jerks right part
of face.
• Tumor left hemisphere (PAD: multifocal
malignant PNET)

HL 2002 vEEG

Ingmar Rosen, MD: Jan. 17, 2008 14


aEEG monitoring of recovery
after global brain ischemia

Acute effects of global brain ischemia and recovery

Prior and Maynard

Gavilanes

Watanabe

Continuous aEEG/EEG monitoring during and after hypothermia treatment


following cardiac arrest in adults- study design
Rundgren, Rosén, Friberg. Intensive Care Medicine 2006

CA+ROSC Normothermia Neurol ex Neurol ex

Target
temp Rewarm
Cooling

4h 24h 8h 24h 48h

Continuous
aEEG mon SSEP SSEP
2ch MR MR N20/P25

EP
C3-P3 1 iE-cE N18

P14
2
C4-P4 3 N13 C5-cE
4
N18 Fz EP N13

P14
N20 -
cC
cEms
10
P-
P25 1 uV
Fz

Ingmar Rosen, MD: Jan. 17, 2008 15


A B

Flat S-B

C D

SE
Continuous

Table 1: Cerebral Performance Category (CPC) scale


CPC 1: Good cerebral performance: conscious, alert, able to work
CPC 2: Moderate cerebral disability: conscious, can carry out independent
activities
CPC 3: Severe neurological disability: conscious, dependent on others for daily
support
CPC 4: Coma or vegetative state
Continuous
CPC 5: Dead
CPC
EEG
1: 11
without
2:6
ESE
3:3
n=20
34 patients

Flat: 5 CPC
SB: 3 1-3:0
ESE: 6 5:14

Conclusion
• Continuous simplified aEEG monitoring is
technically feasible in the adult ICU
• The EEG pattern at normoterm (36h) but
not within the first few hours predics
outcome in terms of survival
• Continuous epileptiform activity with onset
within 24 h after CA is a serious predictive
sign.
Rundgren,Rosén,Friberg
Int Care Med 2006

Ingmar Rosen, MD: Jan. 17, 2008 16


aEEG-monitoring after cardiac
arrest (RH-2007)
• 5 m girl with craniosynostosis(op) and
acyanotic Fallot
• Delayed myelinization
• 2 days post card op cardiac arrest for 5
min
• Hypothermia for 24 h
• Development of clinical seizures

RH-2007

1 d (normothermia) 3d

2d 5d

RH-2007

Ingmar Rosen, MD: Jan. 17, 2008 17


aEEG-monitoring after severe
asphyxia and cardiac arrest
(EL-88)
• Girl 17 y
• Came under a dead horse during horse
competition
• RLS 8 when rescucitated after 15 min.
• Hypothermia treatment for 48h

0d 1d

2d

EL-88

aEEG-monitoring after cardiac


arrest (ZE-91)
• 16 y boy
• Ventricular fibrillation
• Rapid rescusitation-45 min to spont.cirk.
• Initially unconscious
• Hypothermia treatment

Ingmar Rosen, MD: Jan. 17, 2008 18


1d

2d

ZE-91

Applications of aEEG trend monitoring in


paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus
• Detection of rare seizure patterns in immobilized
children
• Useful tool in full video-EEG monitoring for
detection of clinically silent seizures
• Adds prognostic information after severe
ischemic insult/cardiac arrest

• Full EEG and aEEG/EEG combined is


imperative in most cases

Mobile
unit

CHICU

Server ICU
NFK
NICU USiL

NFK Stroke
NICU
UMAS NL

Networking facilitates
Interdisciplinary interaction ! Mobile
ICU

Ingmar Rosen, MD: Jan. 17, 2008 19