Amplitude integrated EEG

beyond the NICU

Ingmar Rosén
Division of Clinical Neurophysiology
Department of Clinical Science Lund
Lund University

•Restoration of EEG background

•Detection of seizure events>> SE

Prior and Maynard

Old CFM in neonatal monitoring

10 days of CFM !

Ingmar Rosen, MD: Jan. 17, 2008 1

 Old CFM-problems
• Artefacts (movements,care procedures,
ECG, high frequency ventilation)

• Lack of correllation with the original EEG

signal.

• Neonatal aEEG interpretation became an

art of its own, independent of the vast
EEG-knowledge/experience

CFM/aEEG development

New aEEG/EEG
• Shows the real EEG

• Stores digital EEG, available for review

and reanalysis

• Flexibility – trends, number of

channels, time resolution

New aEEG/EEG monitors by: BrainZ,

Viasys, Olympic, Micromed, Day One

Ingmar Rosen, MD: Jan. 17, 2008 2

 Patterns discernable by simplified
aEEG/EEG monitoring

• Pathology of EEG background-prognosis

• Monitoring before-during-after
hypothermia

• Seizure patterns-possibility to treat

Applications of aEEG trend monitoring in

paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus and follow up of
acute treatment

• Detection of rare seizure patterns in immobilized

children

• Useful tool in full video-EEG monitoring

• Contributes to prognosis after severe ishemic

insult/cardiac arrest

aEEG and SE monitoring

• The additional value of aEEG monitoring is
depending upon type and EEG features of
the SE

• An early full EEG is recommended and is

often used for tailoring the monitoring

Ingmar Rosen, MD: Jan. 17, 2008 3

 EEG message in SE

High intensity Risk of excitotoxic

seizure pattern injury

Repetitive focal Immediate interference

or generalized with cognition/consciousness
spiking

ESES Deleterious plastic

CSWS effects on brain
Epileptic encephalopathy functional development
of childhood

Progress of generalized convulsive SE

(Treiman)

Start of clinical seizure

Ingmar Rosen, MD: Jan. 17, 2008 4

 Continuous generalized seizure pattern

EEG

Seizure pattern arrested by propofol

Continuous EEG

EEG

Seizure pattern arrested by propofol

Burst-Suppression pattern

Ingmar Rosen, MD: Jan. 17, 2008 5

 Status epilepticus (AD-2003)
• 4 y girl
• Olfactory neuroblastoma, posterior
fossa+front dx
• Post op unconscious suspected seizures
• Full EEG
• 2 channel aEEG/EEG monitoring

AD-2003

Ingmar Rosen, MD: Jan. 17, 2008 6

 AD-2003-mon d1

AD-2003-mon d 9

AD-2003-mon d 9

Ingmar Rosen, MD: Jan. 17, 2008 7

 Focal seizures and limited
number of recording channels
How serious is the problem ?

With tailored design sufficient sensitivity is

attained with few recording channels (and
electrodes)

The brain is a volume conductor

3 focal seizures with different locations all appear in one channel aEEG trace

P3-P4

C3-P3

C4-P4
A

Ingmar Rosen, MD: Jan. 17, 2008 8

 TN (severe epileptic
encephalopathy)
• Girl born 34+5 w. Pre-eclampsia.
• 6d gen seiz ; Phbarb, Fos-phen, Midazol.
• Seizure free from 10 d
• 2 m foc seiz left eye+ hand + gen ton s
• Repeated seizure periods
• 5 m EEG: Hypsarrythmia. Therapy resistent
• 11m Ketogenic diet with some improvement;
several seizure types

TN 2 m seizure

TN 2 m ii

Ingmar Rosen, MD: Jan. 17, 2008 9

 TN 2 m i

TN 11 m

TN 11 m

Ingmar Rosen, MD: Jan. 17, 2008 10

 aEEG and SE monitoring
• The additional value of aEEG monitoring is depending
upon type and EEG features of the SE

• An early full EEG is recommended and is often used for

tailoring the monitoring

• Flexibility of channel number, position, and trend mode is

an advantage

• 2 channel (F3-P3; F4-P4) aEEG/EEG recording

recommended after the neonatal period

Green hours

Monitor Final
Acute EEG
tailored Sum up

Red hours

Final
Monitor Monitor
EEG Sum up
standard tailored

Seizure detection (EK-2007)

• 7 m girl with achondroplasia
• Decompressive surgery posterior fossa
• Post op hiccups and apnoeic episodes
• Full EEG: diffuse slowing-no epileptiform
activity
• Seizures ?

Ingmar Rosen, MD: Jan. 17, 2008 11

 EK-2007

1
3

EK-2007

Suspected seizures (AG-2003)

• 4 y girl from Kosovo
• Severe perinatal cerebral lesion
( mechonium aspiration reported)
• Severe dystonic CP
• Microcephaly with extensive cortical and white
matter lesions
• EEG: pathological with interictal positive sharp
waves right side
• Frequent attacks of extension –seizures ?

Ingmar Rosen, MD: Jan. 17, 2008 12

 AG-2003

AG-2003

AG-2003

Ingmar Rosen, MD: Jan. 17, 2008 13

 AG-2003

Video-EEG(HL-2002)
• 5y girl
• Short history of focal epilepsy
• Subtle episodes with absense sometimes
drawling, sometimes subtle jerks right part
of face.
• Tumor left hemisphere (PAD: multifocal
malignant PNET)

HL 2002 vEEG

Ingmar Rosen, MD: Jan. 17, 2008 14

 aEEG monitoring of recovery
after global brain ischemia

Acute effects of global brain ischemia and recovery

Prior and Maynard

Gavilanes

Watanabe

Continuous aEEG/EEG monitoring during and after hypothermia treatment

following cardiac arrest in adults- study design
Rundgren, Rosén, Friberg. Intensive Care Medicine 2006

CA+ROSC Normothermia Neurol ex Neurol ex

Target
temp Rewarm
Cooling

4h 24h 8h 24h 48h

Continuous
aEEG mon SSEP SSEP
2ch MR MR N20/P25

EP
C3-P3 1 iE-cE N18

P14
2
C4-P4 3 N13 C5-cE
4
N18 Fz EP N13

P14
N20 -
cC
cEms
10
P-
P25 1 uV
Fz

Ingmar Rosen, MD: Jan. 17, 2008 15

 A B

Flat S-B

C D

SE
Continuous

Table 1: Cerebral Performance Category (CPC) scale

CPC 1: Good cerebral performance: conscious, alert, able to work
CPC 2: Moderate cerebral disability: conscious, can carry out independent
activities
CPC 3: Severe neurological disability: conscious, dependent on others for daily
support
CPC 4: Coma or vegetative state
Continuous
CPC 5: Dead
CPC
EEG
1: 11
without
2:6
ESE
3:3
n=20
34 patients

Flat: 5 CPC
SB: 3 1-3:0
ESE: 6 5:14

Conclusion
• Continuous simplified aEEG monitoring is
technically feasible in the adult ICU
• The EEG pattern at normoterm (36h) but
not within the first few hours predics
outcome in terms of survival
• Continuous epileptiform activity with onset
within 24 h after CA is a serious predictive
sign.
Rundgren,Rosén,Friberg
Int Care Med 2006

Ingmar Rosen, MD: Jan. 17, 2008 16

 aEEG-monitoring after cardiac
arrest (RH-2007)
• 5 m girl with craniosynostosis(op) and
acyanotic Fallot
• Delayed myelinization
• 2 days post card op cardiac arrest for 5
min
• Hypothermia for 24 h
• Development of clinical seizures

RH-2007

1 d (normothermia) 3d

2d 5d

RH-2007

Ingmar Rosen, MD: Jan. 17, 2008 17

 aEEG-monitoring after severe
asphyxia and cardiac arrest
(EL-88)
• Girl 17 y
• Came under a dead horse during horse
competition
• RLS 8 when rescucitated after 15 min.
• Hypothermia treatment for 48h

0d 1d

2d

EL-88

aEEG-monitoring after cardiac

arrest (ZE-91)
• 16 y boy
• Ventricular fibrillation
• Rapid rescusitation-45 min to spont.cirk.
• Initially unconscious
• Hypothermia treatment

Ingmar Rosen, MD: Jan. 17, 2008 18

 1d

2d

ZE-91

Applications of aEEG trend monitoring in

paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus
• Detection of rare seizure patterns in immobilized
children
• Useful tool in full video-EEG monitoring for
detection of clinically silent seizures
• Adds prognostic information after severe
ischemic insult/cardiac arrest

• Full EEG and aEEG/EEG combined is

imperative in most cases

Mobile
unit

CHICU

Server ICU
NFK
NICU USiL

NFK Stroke
NICU
UMAS NL

Networking facilitates
Interdisciplinary interaction ! Mobile
ICU

Ingmar Rosen, MD: Jan. 17, 2008 19