Rhythmic Blueprints: A tutorial on Design and Evaluation of Rhythmic Interaction
Periodic and Rhythmic Patterns - Capítulo Cubano de ...
Transcript of Periodic and Rhythmic Patterns - Capítulo Cubano de ...
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Periodic and Rhythmic Patterns
Suzette M LaRoche, MD
Mission Health Epilepsy Center
Asheville, North Carolina
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Continuum of EEG Activity
Triphasics
GPDs LRDA
Burst-SuppressionSIRPIDs
?
NCSE
Clinical Correlate
NCS
Frequency, Duration, Rhythmicity, Location
LPDs +
LPDs
Neuronal Injury
BRDs
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American Clinical Neurophysiology Society (ACNS): Critical Care EEG Terminology
Main Term #2
Periodic Discharges
PD s
Rhythmic Delta Activity
RDA
Spike-wave
SW
Main Term #1
Generalized
G
Lateralized
L
Bilateral Independent
BI
Multifocal
Mf
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Main Term 1: Location
• Generalized
– Symmetric in both hemispheres
• Lateralized
– Seen in only one hemisphere: unilateral
– Seen in both hemispheres but asymmetric: Bilateral asymmetric
• Bilateral Independent
– Seen in both hemispheres but Asynchronous
• Multifocal
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Main term 2: Pattern Type• Periodic Discharge (PD)
– Repetition of a waveform with uniform morphology
– Quantifiable interval between waveforms
• Rhythmic Delta Activity (RDA)
- Repetition of a waveform with uniform morphology
- No interval between consecutive waveforms
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Modifiers
• Amplitude
• Frequency
• Prevalence (how much of the recording?)
• Plus (superimposed Fast, Rhythmic, Sharp)
• Stimulus Induced (SIRPIDs)
• Triphasic Morphology
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Lateralized Periodic Discharges: LPDs
Etiologies:
Stroke
Encephalitis (HSV)
Tumor
Intracranial hemorrhage
Clinical Correlates:
Acute injury
Encephalopathy
Seizures in 50-90%
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Lateralized Periodic Discharges
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Lateralized Periodic Discharges Plus
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Bilateral Independent Periodic Discharges (BIPDs)
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Left Face Twitch: “ictal” LPDs
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Generalized Periodic Discharges: GPDs
Clinical Correlate:
SEIZURES??
Outcome?
Etiologies:
Anoxia
Toxic metabolic
Infections (CJD)
Focal structural lesions
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Generalized Periodic Discharges:Relationship to Seizures and Prognosis
• Patients with GPDs were matched by age, etiology, level of consciousness to patients without GPDs (200
each)
Foreman et al, Neurology 2012
GPDs Control p value
Any seizure during hospitalization 46% 34% 0.014
Non-convulsive seizure 27% 8% <0.001
NCSE 22% 7% <0.001
Mortality (univariate)* 36.8% 26.9% 0.049
*Multivariate predictors of worse outcome were cardiac arrest, coma, nonconvulsive status epilepticus, and sepsis, but not generalized periodic
discharges.
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GPDs with Triphasic Morphology (old term: Triphasic Waves)
• High amplitude, positive discharge
• Each phase longer than the preceding
• Frontally predominant +/- A-P lag
• Hepatic or renal encephalopathy, anoxia, seizures?
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Generalized Periodic Discharges:Clinical Significance of Triphasic Morphology
Foreman et al, Clin Nphys, 2015
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Lateralized Rhythmic Delta Activity (LRDA)
Gaspard et al. JAMA
Neurology 2013
27 patients/570 (4.7%)
Control populations
• Lateralized Periodic Discharges: N = 49
• Focal slowing: N = 136
• No focal, periodic or rhythmic pattern: N = 241
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LRDA: Risk of acute seizures
Gaspard et al, JAMA Neurology, 2013
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Continuous EEG Monitoring Consortium Training Module
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Generalized Rhythmic Delta Activity (GRDA)
• High amplitude, bisynchronous slow waves
• Typical frequency of 2- 2.5 Hz
• Typically seen in toxic-metabolic disturbances
• May see with large midline structural lesions or increased ICP with herniation
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Brief (potentially ictal)Rhythmic Discharges
B(i)RDs, BRDs
“Evolving rhythmic patterns…. less than 10 seconds”
Tsuchida et al, Neonatal ICU EEG Terminology, J Clin Neurophys 2013
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B(i)RDs and Association with Seizures
Yoo et al, JAMA Neurology, 2014
• 20 adult patients with B(i)RDs and compared to control groups
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Continuous EEG Monitoring Consortium Training Module
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Hirsch et al, Epilepsia 2004
SIRPIDS= Stimulus induced rhythmic, periodic or ictal discharges
• 33 of 150 pts. undergoing cEEG (22%)
• 50% experienced clinical or subclinical seizures during hospitalization
• Reactivity? Pathophysiology?
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Term % Agreement (SD) Kappa (95% CI) Agreement
Main Term 1 Generalized
Lateralized
Bilateral Independent
Multifocal
96% (7%) .87 (.75-.98) Almost Perfect
Main Term 2 Periodic Discharges
Rhythmic Delta Activity
Spike-Wave
98% (3%) .92 (.78-.98) Almost Perfect
Modifiers Amplitude 93% (12%) n/a
Frequency 80% (20%) n/a
+ Fast 83% (18%) .54 (.16-.87) Fair
+ Rhythmic Activity 88% (20%) .62 (.41-.87) Moderate
+ Sharp or Spike 82% (20%) .16 (.10-.28) Poor
Mani et al Journal Clin Neurophysiol 2012
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Periodic and Rhythmic Patterns: Association with Seizures
• Retrospective, 3-center review of 4772 critically ill adults undergoing CEEG
• Seizures were documented in 719 (12.5%) of which 530 (74%) also had a periodic or rhythmic pattern
Rodriguez et al, presented at AES, December 2015
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Pattern Frequency
Sei
zure
Ris
k
Significant Risk
GRDA - GRDA +
1.5 Hz
LPD +
Periodic and Rhythmic Patterns:
Association with Seizures
Rodriguez et al, presented at AES, December 2015
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Case
• 66 yo man with 4 months of cognitive decline and gait instability
• Medications: Methadone, Diazepam
• Neurological Exam: Oriented to person only, bilateral visual field deficits, strength intact, reflexes brisk throughout,
multifocal myoclonus, unable to stand
• Initial Diagnostic Tests:
• MRI partially obscured due to movement artifact but essentially unremarkable
• CSF – Protein 35, Glucose 67, WBC 3/ 4
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Lateralized Periodic Discharges (LPDs)- Not Ictal
Load Fosphenytoin 20 mg/kg/PELoad Fosphenytoin 20 mg/kg/PE
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2 weeks later….
CSF Analysis: 14, 3, 3 Protein Tau/Theta Positive
Clinical Diagnosis: Creutzfeldt – Jacob Disease
Deceleration of Care
CSF Analysis: 14, 3, 3 Protein Tau/Theta Positive
Clinical Diagnosis: Creutzfeldt – Jacob Disease
Deceleration of Care
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Case
• 85 yo admitted for fever, productive cough and confusion
• Medications: Albuterol, Lisinopril
• Neurological Exam: Lethargic, oriented to person only, unable to follow commands, otherwise non focal
neurological exam
• Chest X ray: Bilateral pulmonary infiltrates
• Brain MRI: Mild generalized volume loss
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EEG 2 Days later: No improvement in mental status
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Generalized Periodic Discharges (GPDs), 1.5-2 Hz, with triphasic morphology
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5 min after Lorazepam 2 mg: Awake, Follows Commands
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Case
• 44 yo woman with shortness of breath and confusion
• Medications: Oxycodone
• Urine Drug Screen: Positive for opiates, benzodiazepines
• Head CT: Unremarkable
• Intubated and sedated (with propofol) secondary to respiratory distress, possible overdose
• Neurology consult 2 days later for persistent confusion
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EEG During Propofol Wean: Generalized Rhythmic Delta Activity (GRDA), 2 Hz, Plus
Sharp
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Also…. Fluctuating
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Also… Stimulus Induced Rhythmic, Periodic or Ictal Discharges (SIRPIDs)
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Next day, propofol off…..transferred out of ICU
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Summary
• Periodic and rhythmic patterns are common in the critically ill, many of which have increased association with seizures
• Standardized terminology is critical for consistency in clinical reporting and research
• Medical decisions need to take into account the EEG pattern AND clinical history