Kenneth G' Jordan, MD, FACP, FACNS President, Jordan NeuroScience , Inc

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ICU/ER EEG MONITORING
WSET 2007
Kenneth G. Jordan, MD, FACP, FACNS President,
Jordan NeuroScience , Inc
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DISCLOSURES

• 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

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EEG and EKG Analogous Tools
THE BRAIN PURKINJE SYSTEM
THE PURKINJE SYSTEM
NORMATIVE SURFACE FIELDS
NORMATIVE SURFACE FIELDS
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CEEG EKG MONITORING
OF THE BRAIN

EKG
EEG
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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.
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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

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Detection of
Subclincal Seizures
The Critical Care EMU
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PERSISTING COMA WITH SMALL SDH
From
Jordan KG. JCN(1999)1614-39
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STABLE ICH WITH DECLINING GCS
PLEDS on Standard EEG NCSE
on ICU-CEEG
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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
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NCSE in Hepatic Encephalopathy
AMMONIA LEVEL135
AMMONIA LEVEL UNCHANGED
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NCS/NCSE OCCUR COMMONLY
IN ALL TYPES OF ABI

(Table shows NCSE / NCS)

Monitored 48-72 hours to R/O NCSE
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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.

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Residual 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
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Persistent 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
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NCSE 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
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NCSE and Excitotoxicity in Head
Trauma
Glutamate
Courtesy of Paul Vespa, MD UCLA School of Medicine
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INDETERMINATE PATTERNS
GPEDS
SIRPIDS
PERIODIC TRIPHASIC WAVES
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Chong and
Hirsch, JCN 2005
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DETECTNG AND MONITORING CEREBRAL ISCHEMIA
Based on Jordan KG.
JCN(2004)21341-352)
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EEG Changes in Carotid Clamping
1-70 Hz
Sundt et al. Mayo Clin Proc. 1978
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Jordan K. JCN 2004
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CBF-EEG CORRELATION IN AIS
A
CBF16.1
B
C
50uV x 1sec
LF1Hz HF70Hz
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(No Transcript)
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RCBF 17
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RCBF 79
Normalized EEG Resolved Deficits
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Alpha Variability And Alpha-delta Ratio In SAH
Vasospasm
(Classen et al, JCN 2005 Vespa
et al. Electroenceph. Clin. Neurophys. 1997)
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(No Transcript)
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DAY 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
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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
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JORDAN, K. J.CLIN. NEUROPHYS 1999
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THE NEW ERA OF ACUTE EEG
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RAPID (Set-Up), REALTIME (Monitoring), REMOTE
(Connectivity) CEEG
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Rapid BraiNet Set-Up
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Monitor 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

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Courtesy Mark Sheuer, MD
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Courtesy Mark Sheuer, MD
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Courtesy Mark Sheuer, MD
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Courtesy Mark Sheuer, MD
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Internet Connectivity
(Courtesy of Susan Herman, MD)
Secure Web Server
Home Computer
Database Server
The Internet
Firewall
Wireless Transceiver
Mobile Devices
Data Encryption
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Remote 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
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• 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
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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
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Diagnostic 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)
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Realtime EEG Network
Ambulance
ER
ICU
Bidirectional Remote Real-time
EEG
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THANKS FOR YOUR ATTENTION