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OBJECTIVE: To assess clinical and electroencephalogram (EEG) predictors of epilepsy and to describe the percentage of electrographic seizures (ES) and development of epilepsy among patients with spontaneous intracerebral hemorrhage (ICH) due to arteriovenous malformation (AVM) rupture. STUDY DESIGN: Retrospective review of patients admitted to the pediatric intensive care unit with ICH secondary to AVM rupture over 11 years. Clinical variables were collected by review of the electronic medical record. Seizures were described as acute symptomatic (7 days after AVM rupture), subacute (7-30 days after AVM rupture) and remote (greater than 30 days after AVM rupture). Outcome metrics included mortality, and the development of epilepsy post discharge. Descriptive statistics were used. RESULTS: Forty-three patients met inclusion criteria with a median age of 12.2 years (IQR 7.3-14.8) and 49% (21/43) were female. Sixteen percent (7/43) presented with a clinical seizure prior to EEG placement. EEG was performed in 62% (27/43) of patients; one had electrographic status epilepticus without clinical signs. Sixteen percent (7/43) of patients were diagnosed with epilepsy, with a median time to diagnosis of 1.34 years (IQR 0.55-2.07) after AVM rupture. One-year epilepsy free survival was 84% (95% CI 70%-98%) and two-year epilepsy free survival was 79% (95% CI 63%-95%) Remote seizures were associated with epilepsy (p<0.001), but acute symptomatic seizures were not (p=0.16). CONCLUSIONS: EEG-confirmed seizures are uncommon in patients with ICH secondary to AVM rupture; however when identified, the seizure burden appears to be high. Patients with seizures 30 days after AVM rupture are more likely to develop epilepsy.
RESUMO
BACKGROUND: The ictal-interictal continuum (IIC) consists of several electroencephalogram (EEG) patterns that are common in critically ill adults. Studies focused on the IIC are limited in critically ill children and have focused primarily on associations with electrographic seizures (ESs). We report the incidence of the IIC in the pediatric intensive care unit (PICU). We then compare IIC patterns to rhythmic and periodic patterns (RPP) not meeting IIC criteria looking for associations with acute cerebral abnormalities, ES, and in-hospital mortality. METHODS: This was a retrospective review of prospectively collected data for patients admitted to the PICU at Children's National Hospital from July 2021 to January 2023 with continuous EEG. We excluded patients with known epilepsy and cerebral injury prior to presentation. All patients were screened for RPP. The American Clinical Neurophysiology Society standardized Critical Care EEG terminology for the IIC was applied to each RPP. Associations between IIC and RPP not meeting IIC criteria, with clinical and EEG variables, were calculated using odds ratios (ORs). RESULTS: Of 201 patients, 21% (42/201) had RPP and 12% (24/201) met IIC criteria. Among patients with an IIC pattern, the median age was 3.4 years (interquartile range (IQR) 0.6-12 years). Sixty-seven percent (16/24) of patients met a single IIC criterion, whereas the remainder met two criteria. ESs were identified in 83% (20/24) of patients and cerebral injury was identified in 96% (23/24) of patients with IIC patterns. When comparing patients with IIC patterns with those with RPP not qualifying as an IIC pattern, both patterns were associated with acute cerebral abnormalities (IIC OR 26 [95% confidence interval {CI} 3.4-197], p = 0.0016 vs. RPP OR 3.5 [95% CI 1.1-11], p = 0.03), however, only the IIC was associated with ES (OR 121 [95% CI 33-451], p < 0.0001) versus RPP (OR 1.3 [0.4-5], p = 0.7). CONCLUSIONS: Rhythmic and periodic patterns and subsequently the IIC are commonly seen in the PICU and carry a high association with cerebral injury. Additionally, the IIC, seen in more than 10% of critically ill children, is associated with ES. The independent impact of RPP and IIC patterns on secondary brain injury and need for treatment of these patterns independent of ES requires further study.