Title: Kenneth G' Jordan, MD, FACP, FACNS President, Jordan NeuroScience , Inc
1ICU/ER EEG MONITORING
WSET 2007
Kenneth G. Jordan, MD, FACP, FACNS President,
Jordan NeuroScience , Inc
2DISCLOSURES
- President and shareholder of Jordan NeuroScience,
Inc., a medical device manufacturer in the field
of acute EEG monitoring - Certain JNS proprietary products and methods are
included in this presentation. - No external funding sources
3EEG and EKG Analogous Tools
THE BRAIN PURKINJE SYSTEM
THE PURKINJE SYSTEM
NORMATIVE SURFACE FIELDS
NORMATIVE SURFACE FIELDS
4 CEEG EKG MONITORING
OF THE BRAIN
EKG
EEG
5 A Brief History of CEEG
- 1970s EMU, OR Carotid Monitoring, CFM in UK
- 1980s CSA for coma trending first Neuro ICUs
- 1990s Digital EEG Revolution bedside CEEG
detects high incidence of NCS/NCSE in ABI, guides
intervention. - 2000s Expansion of Neuro ICUs and ICU-CEEG.
Thanks to digital EEG, NICUs and awareness of
NCSE, my brain is now monitored with CEEG.
6 INDICATIONS FOR ICU-CEEG (Vespa et al.
JCN 1999, Hirsch. JCN 2004)
- Detection of subclinical seizures
- Differentiate non-seizure paroxysmal events
- Management of burst-suppression medical coma
- Detecting cerebral ischemia
- Monitoring level of sedation
- Monitoring response to interventions
7 Detection of
Subclincal Seizures
The Critical Care EMU
8PERSISTING COMA WITH SMALL SDH
From
Jordan KG. JCN(1999)1614-39
9 STABLE ICH WITH DECLINING GCS
PLEDS on Standard EEG NCSE
on ICU-CEEG
10 EEG CRITERIA for NONCONVULSIVE SEIZURE
- Guideline At least one primary criterion and the
secondary criterion. Discharges are
? 10 seconds in duration - Primary criteria
- Repetitive generalized or focal spikes, sharp
waves, spike-and-wave or sharp-and-slow wave
complexes at gt 3/second. - Repetitive generalized or focal spikes, sharp
waves, spike-and-wave or sharp-and-slow wave
complexes at lt 3/second and secondary criterion. - Sequential rhythmic, periodic or quasi-periodic
waves at gt/ 1/sec with unequivocal evolution in
frequency, location , or morphology. -
-
Secondary criterion - Significant improvement in clinical
state, resolution of epileptiform activity, and
improvement of background EEG patterns (e.g.
re-appearance of posterior dominant rhythm)
temporally linked to intravenous administration
of rapidly acting anti-epileptic drug.
After Young GB, Jordan KG. Neurology, 1996, with
modifications by Chong DJ, Hirsch LJ. JCN 2005
11NCSE in Hepatic Encephalopathy
AMMONIA LEVEL135
AMMONIA LEVEL UNCHANGED
12 NCS/NCSE OCCUR COMMONLY
IN ALL TYPES OF ABI
(Table shows NCSE / NCS)
Monitored 48-72 hours to R/O NCSE
13 HIERARCHY OF RISK FOR NCS/NCSE
- 1. CSEgtINFgtNSGgtSAHgtTBIgtMEgtALOCgtICHgtAIS
- 2. Incidence of NCS is 8-48, depending on Dx
- 3. Incidence of NCSE is 8-20, depending on Dx
- 4. NCSE occurs in av. 47 of patients with NCS.
14Residual Electrographic SE After Control Of
Visible SE
- 130 overt GCSE patients in whom EEG monitoring
was begun within 30 minutes of start of treatment - 26/130 (20) remained in electrographic SE after
motor movements had stopped (twitchless
electrical activity)
Faught Epilepsia 1998
15Persistent Nonconvulsive SE After The Control Of
Convulsive SE
- 52 had no after-SE ictal discharges
- EEG showed generalized slowing, attenuation,
PLEDS, focal slowing, and/or burst suppression - The remaining 48 demonstrated persistent
electrographic seizures - over 14 manifested NCSE, predominantly CPSE
DeLorenzo et al Epilepsia 199839833-40
16NCSE MORTALITY
- Etiology
- Remote symptomatic 16 (4/25) p 0.009
- Acute symptomatic 46 (11/24) OR 6.0
- NCS vs. NCSE (AS and RS) p 0.002
- - 12 vs. 54 OR10.0
- Seizure Duration
- lt10 h 10 (3/30)
p 0.0006 - 10-20 h 33 (2/6) OR
1.093/h - gt20 h 85 (11/13)
- Delay to Diagnosis
- lt0.5 h 36 (5/14)
- gt1 lt24 h 39 (7/18) p
0.00001 - ?24 h 75 (6/8)
Young GB, Jordan KG., Doig G. Neurology, 1996
17 NCSE and Excitotoxicity in Head
Trauma
Glutamate
Courtesy of Paul Vespa, MD UCLA School of Medicine
18INDETERMINATE PATTERNS
GPEDS
SIRPIDS
PERIODIC TRIPHASIC WAVES
19 Chong and
Hirsch, JCN 2005
20DETECTNG AND MONITORING CEREBRAL ISCHEMIA
Based on Jordan KG.
JCN(2004)21341-352)
21 EEG Changes in Carotid Clamping
1-70 Hz
Sundt et al. Mayo Clin Proc. 1978
22 Jordan K. JCN 2004
23 CBF-EEG CORRELATION IN AIS
A
CBF16.1
B
C
50uV x 1sec
LF1Hz HF70Hz
24(No Transcript)
25RCBF 17
26RCBF 79
Normalized EEG Resolved Deficits
27 Alpha Variability And Alpha-delta Ratio In SAH
Vasospasm
(Classen et al, JCN 2005 Vespa
et al. Electroenceph. Clin. Neurophys. 1997)
28(No Transcript)
29DAY 1 APHASIC DROWSY
TCD220
BP160/110 (MAP110)
Bilaterally Abnormal EEG LgtR
VASOSPASM
Inferred RCBF LFT critical at 10-15
ml/100g/min RHem moderate at 18-25
30 DAY 12 NML
TCD112 BP140/80 (MAP100)
DAY 3NML
TCD180 BP200/110 (MAP150)
Normal
Improving
EEG worsens with in MAP
EEG stable with in MAP
Impaired cerebral autoregulation
Return of normal cerebral autoregulation
31JORDAN, K. J.CLIN. NEUROPHYS 1999
32 THE NEW ERA OF ACUTE EEG
33RAPID (Set-Up), REALTIME (Monitoring), REMOTE
(Connectivity) CEEG
34Rapid BraiNet Set-Up
35Monitor Quantitatively
Courtesy of Susan Herman, MD
- Fast Fourier transformation of EEG data
- Color spectrograms
- Hidden line compressed spectral arrays
- Density spectral array
- Displays of total power in certain frequency
bands - Ratios of power in certain bands to others or to
broader spectrum of EEG power - Spectral edge displays
- Amplitude integrated EEG
- Coherence
36 Courtesy Mark Sheuer, MD
37 Courtesy Mark Sheuer, MD
38 Courtesy Mark Sheuer, MD
39 Courtesy Mark Sheuer, MD
40 Internet Connectivity
(Courtesy of Susan Herman, MD)
Secure Web Server
Home Computer
Database Server
The Internet
Firewall
Wireless Transceiver
Mobile Devices
Data Encryption
41Remote CEEG Monitoring
1. Continuous real-time, 2. Continuous near
real-time, 3.
Post hoc periodic event based review
EEG Super Tech at home
ICU Nurse with ICU-CEEG
MD checking ICU-CEEG on Handheld
MD Checking ICU-CEEG from Office
42- ER-EEG If Time is Brain,
We Must Start
Early
Delay in NCSE 1-2/hr increased mortality.
- (Young, Jordan. NCSE in the Neuro ICU.
Neurology 1996)
- NCSE often goes unrecognized or is mistaken for
behavioral or psychiatric disturbance. (1) - 31 of patients with convulsive SE persist in
NCSE after adequate treatment. (2) - 7-14 of ED Sz or ALOC pts had NCSE by EEG
(3,4,5) - 16-37 of ED ALOC pts had definite NCSE or
active epileptic spikes on EEG (6)
Generalized NCSE in 78yo F treated for CSE who
remained lethargic after convulsions stopped.
Refs 1) Kaplan. Epilepsia 1996 2)Treiman et al.
NEJM 1998 3) Alehan. J. Child Neurol 2001 4)
Jordan. J Clin Neurophys. 2004 5) Rotenberg et
al. Neurol (Supp 1) 2005 6) Privatera. Epil.
Res. 1994
43 ER-EEG Nonepileptic Seizures
(Pseudo) Seizures
- Range of 8-26 incidence of ED Sz pts have
unsuspected NES found by EEG (1,2,3) - 10 pts with presumed epileptic status had
pseudo-status by EEG (3) - Risk of AEDs, IV sedation, intubation, and death
from unrecognized NES (4)
Normal EEG activity with movement artifact in
actively seizing patient with NES (red
rectangle)
Refs 1. Jordan et al. J. Neuro Crit Care 2004
2. Bastani et al. Neurol (Supp 1) 2005
(3)Rotenberg et al. Neurol (Supp. 1) 2005 4)
Reuber et al Neurol. 2004
44Diagnostic Impact Of ER-EEG
ER Dx 141 Sz, 23 SE 164
ER-EEG Dx
12/73 (16) ALOC
Focal or generalized repetitive epileptic focus
on postictal or interictal EEG
Jordan K, Schneider A. Neurocritical
Care 2004 1257 (abstr)
45Realtime EEG Network
Ambulance
ER
ICU
Bidirectional Remote Real-time
EEG
46 THANKS FOR YOUR ATTENTION