Authors :
Presenting Author: Alexis Boro, MD – Albert Einstein College of Medicine and the Montefiore Health System
Presenting Author: Alexis Boro, MD – Albert Einstein College of Medicine
Ibrahim Migdady, MD – The Saul R. Korey Department of Neurology, The Jay B. Langner Critical Care Service, Leo M. Davidoff Department of Neurological Surgery – Albert Einstein College of Medicine and the Montefiore Health System; Austin Saline, MD – The Saul R. Korey Department of Neurology – Albert Einstein College of Medicine and the Montefiore Health System; Alexis Boro, MD – The Saul R. Korey Department of Neurology – Albert Einstein College of Medicine and the Montefiore Health System; Rishi Malhotra, MD – The Saul R. Korey Department of Neurology, The Jay B. Langner Critical Care Service, Leo M. Davidoff Department of Neurological Surgery – Albert Einstein College of Medicine and the Montefiore Health System
Rationale:
Conventional continuous EEG (cEEG) is often limited by availability or extended wait times for application. As a result, we adopted the use of Ceribell® Rapid Response EEG (rrEEG) in such situations. In this study, we investigate clinicians’ perception of its impact on management, evaluate the concordance rates between rrEEG and subsequent cEEG, and determine the utility of sonification.Methods:
We prospectively collected data from consecutive patients who underwent rrEEG at three Montefiore Medical Center hospitals between August 2019 through February 2020. All epileptologists, critical care physicians, and specific ICU staff underwent mandatory rrEEG training, including a test that required 90% accuracy in categorizing sonification as “positive” or "negative.” Our protocol involved a default four hour rrEEG with sonification at specific intervals. Board-certified epileptologists reviewed the studies in real-time, issuing preliminary reports within the first twenty to sixty minutes, followed by final reports. If the clinical indication persisted, cEEG was performed. Bedside providers completed an eleven element case form for each rrEEG, which included the results of sonification and evaluation of how management was altered by rrEEG.Results:
One hundred consecutive rrEEG studies from 96 patients were reviewed (Table 1). The primary diagnosis was non-neurologic in 38%, and the most common indication for rrEEG was to evaluate for NCSE in the ICU. Data on rrEEG’s impact on management was available for 83 studies, of which 80% changed management, predominantly by preventing escalation or allowing de-escalation of antiepileptic therapy. In 95 studies where sonification data was available, the sensitivity for seizures was 56%, specificity 78%, positive predictive value 35% and negative predictive value 90%.
cEEG was conducted within 48 hours of rrEEG in 76 cases. Common reasons for not pursuing cEEG were resolution of clinical suspicion for seizures, poor prognosis, or mortality prior to cEEG initiation. The rrEEG report was missing in one case. Comparing rrEEG with the first 24 hours of cEEG (n=75), the concordance rate between the two modalities for focal slowing was 56%, sporadic epileptiform discharges 63%, periodic and rhythmic patterns 60%, and seizures 71%. cEEG revealed focal slowing not seen on rrEEG in 31% of studies, sporadic epileptiform discharges in 21%, periodic and rhythmic patterns in 24%, and seizures in 12% (Figure 1). Of 25 cases where seizures were detected, 36% were detected solely on cEEG.
Conclusions:
In the majority of cases, rrEEG with an epileptologist reading in real-time altered management, primarily by mitigating overtreatment. This may lead to lower rates and durations of mechanical ventilation, as well as shorter ICU and hospital length of stays, thereby decreasing complications and cost. Sonification lacks sufficient predictive value to guide triage or management decisions. cEEG often had findings not detected on rrEEG, thus rrEEG as a standalone modality may provide false reassurance. It is crucial to follow up with cEEG unless clinical circumstances no longer warrant it.
Funding: None