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The period following resuscitation after cardiac arrest is a critical time during which the identification and management of neurological injury may lead to increased survival and improved long-term functional outcomes. Neuromonitoring can guide patient management and aid in prognostication following cardiac arrest. EEG background patterns may be useful in outcome prognostication for some patients within 24 hours of cardiac arrest. Similarly, EEG monitoring is often employed for detection of seizures after pediatric cardiac arrest; seizures are common and are most often subclinical. Hypothermia may impact the interpretation and optimal timing of neuromonitoring data used for prognostication. Experts recommend a multimodal approach to prognostication. In this chapter, we discuss cEEG monitoring, quantitative EEG methods for seizure identification, and EEG background interpretation. We discuss SSEPs and NIRS and their respective roles in neurological management and prognostication. We also address how therapeutic hypothermia (TH) and medication exposure can change the reliability of some of these neuromonitoring tools.
The abnormal electroencephalogram (EEG) that attracts the most attention is that showing a seizure. In the intensive care unit (ICU), EEG monitoring is most commonly used for seizure detection; however, EEG can provide additional useful information. The background pattern can be used to evaluate encephalopathy and to assess cerebral function in patients who are sedated and paralyzed. EEG background can inform prognostication after hypoxic ischemic injury. EEG can serve as an ancillary investigation in the determination of brain death. Finally, EEG changes guide titration of treatments, such as continuous infusions administered for status epilepticus or increased intracranial pressure. Quantitative EEG (QEEG) is increasingly used by bedside clinicians for rapid assessment of cerebral function and facilitation of rapid interventions for critically ill patients.
Neurological injury is extremely common among children admitted to the intensive care unit. The importance of recognizing and treating seizures in this vulnerable pediatric population is supported by a growing body of evidence, suggesting that seizures, both clinical and subclinical, negatively impact short- and long-term clinical outcomes. Continuous EEG monitoring offers the only noninvasive means to detect subclinical seizures and to confirm whether paroxysmal events suspicious for seizures do in fact represent clinical seizure activity. This chapter will discuss the evidence to support screening for seizures in specific disease states encountered in the PICU population where clinical and subclinical seizures are common. We begin by outlining the key clinical and EEG risk factors for the development of seizures shared by children admitted to the PICU across all etiologies. We then discuss the etiology-specific risk factors. Finally, considerations related to the timing and duration of cEEG monitoring are discussed.
In the neonatal period, the majority of seizures are acute reactive events provoked by injury. Some etiologies require immediate diagnosis and treatment. Many of these acute, symptomatic seizures resolve once the underlying etiology is corrected or the acute neurological disruption of the causal event subsides. The electroencephalogram (EEG), amplitude-integrated EEG (aEEG), or quantitative electroencephalography (QEEG) may aid in rapid diagnosis and treatment of clinical and subclinical seizures. The new ILAE classification for neonatal seizures emphasizes the need for EEG for accurate diagnosis. Most EEG patterns in the neonate are non-specific to the etiology of seizures. However, even while non-specific, certain patterns can help direct the diagnostic evaluation. In many cases neuromonitoring may have specific characteristics that are helpful to direct further workup. This chapter discusses neuromonitoring in neonatal seizures due to acute causes, including vascular injury (stroke or hemorrhage), infection, acute metabolic disturbance, brain injury of prematurity, and neonatal abstinence syndrome.
Extracorporeal membrane oxygenation (ECMO) is a temporary cardiopulmonary support for neonates and children with potentially reversible cardiopulmonary disorders. Patients requiring ECMO support are at risk for brain injury due to pre-ECMO medical conditions, ECMO cannula placement in the carotid artery and internal jugular vessels, and complications arising during ECMO. Acute brain injury may result in acute symptomatic seizures. Clinical and electrographic seizures are common in neonates and children undergoing ECMO. At the same time, the majority of seizures during ECMO are subclinical, and can only be diagnosed through continuous EEG monitoring. Thus, recent consensus statements have recommended increasing use of continuous EEG monitoring (cEEG) during ECMO in neonates and children. This chapter reviews the available data regarding seizure incidence, risk factors, and outcomes in neonates and children requiring ECMO support.
Neonatal encephalopathy (NE) is the term used to describe persistent neurological dysfunction evident in the first few days after birth. The commonest cause of NE is hypoxia-ischemia, but a similar clinical presentation may occur in other conditions. EEG is essential to grade the severity of neonatal encephalopathy, monitor response to anti-seizure therapy, and to predict outcome early in the neonatal period in infants with NE. Because therapeutic hypothermia is often used in neonatal encephalopathy, the impact of hypothermia on EEG findings is important to consider. EEG evolution and outcome prediction is altered by therapeutic hypothermia. Seizures are common in NE, and seizure burden is also altered by hypothermia. EEG and aEEG can assess severity of NE and predict outcome more accurately than clinical assessment alone. This chapter discusses the various uses of EEG and aEEG in neonatal encephalopathy.
As the population continues to age, clinicians will increasingly encounter neurological conditions in routine clinical practice. Neurological problems in the elderly have a profound impact on quality of life and can at times be life-threatening. Diagnosis and management of geriatric neurological problems is complicated by often vague presentations and the presence of comorbid conditions, as well as complex physiology and pharmacology in this age group. Moreover, when caring for these patients it is of utmost importance to have a holistic approach and include family and caregivers when developing care plans. In this chapter we review muscle weakness, sensory loss, seizure disorders, and headaches in the elderly patient. Causes, impact on quality of life, and available treatment options are discussed. Other topics including delirium, dementia, cerebrovascular disease, and gait disorders will be covered elsewhere.
Takotsubo cardiomyopathy, a disease that causes transient contractile abnormalities mainly in the left ventricular apex, is rarely reported in children, especially in those with single-ventricle disease. A 4-year-old boy with a single right ventricle was transferred to our hospital following a severe seizure and was diagnosed with takotsubo cardiomyopathy by echocardiography. His cardiac function improved; however, he developed hypoxic-ischemic encephalopathy.