Search

The purpose and indications for continuous electroencephalography monitoring (CEEG) in intensive care unit (ICU) patients include seizure detection, monitoring the effects of treatment (including depth of sedation), grading and classification of EEG abnormalities, ischemia detection and prognostication. Practical considerations of ICU CEEG include: choice of montages (patterns of electrode placement and connections), EEG electrodes, recognition of artifacts, and the use of automated or computerized analysis. These aspects are reviewed, along with an identifcation of current advances and challenges for the future of CEEG in the ICU.

Continuous EEG Monitoring is becoming a commonly used tool in assessing brain function in critically ill patients. However, there is no uniformly accepted nomenclature for EEG patterns frequently encountered in these patients such as periodic discharges, fluctuating rhythmic patterns, and combinatio

Objective: To evaluate the possible role of the default mode network (DMN) in consciousness and assess the diagnostic or prognostic potential of DMN connectivity measures in the assessment of a patient group lacking cognitive awareness. Methods: DMN connectivity was established using independent component analysis of resting-state fMRI data in patients with reversible (n = 2) and irreversible (n = 11) coma following cardiac arrest and compared to healthy controls (n = 12). Results: A present and intact DMN was observed in controls and those patients who subsequently regained consciousness, but was disrupted in all patients who failed to regain consciousness. Conclusions: The results suggest that the DMN is necessary but not sufficient to support consciousness. Clinically, DMN connectivity may serve as an indicator of the extent of cortical disruption and predict reversible impairments in consciousness.

The syndrome of involuntary craniofacial lingual movements in the setting of acute intensive care-acquired quadriplegia (critical illness neuromyopathy) following sepsis-associated encephalopathy has not been previously described. We suggest a localization and treatment for this disabling condition.Three patients (2 female) from our center were quadriplegic from critical illness neuromyopathy when they developed involuntary craniofacial lingual movements following sepsis-associated encephalopathy.Extensive investigations failed to identify an etiology for the abnormal movements. Movements were of large amplitude, of moderate speed, and semi-rhythmic in the jaw, tongue, and palate, persistent and extremely bothersome to all patients. Injection with Botulinum toxin type A was very beneficial.Involuntary craniofacial lingual movements in the setting of flaccid quadriplegia following sepsis-associated encephalopathy are consistent with focal craniofacial brainstem myoclonus and constitutes a new syndrome. Botulinum toxin type A treatment maybe helpful in treatment.

Hyperacute hepatic failure (HHF) has a high mortality rate that is most commonly due to severe cerebral edema. However, brain swelling and marked clinical and EEG suppression are potentially reversible, even though the same findings are associated with a very poor neurological outcome in anoxic-ischemic encephalopathy. We present three cases that illustrate neurological recovery despite severe brain swelling and loss of EEG activity. All patients recovered conscious awareness, including one who transiently lost cranial nerve reflexes. Despite deep coma, markedly suppressed EEG and brain edema, aggressive control of ICP may lead to good recovery in acute hepatic failure.

Respiratory electrophysiological studies are of essential value in diagnosing and managing patients with respiratory failure, but assessment of the sensory phrenic nerve fibres has been neglected. We recorded phrenic nerve somatosensory evoked potentials (SSEPs) by combining neurophysiological and neuroimaging techniques in three healthy subjects. Evoked potentials of the phrenic nerve showed the highest amplitude at CP3, determined by the modified 10–20 EEG system, and occurred at a constant latency, PI at 12.0 ± 0.6 ms, and NI at 17.3 ± 0.8 ms. Single photon emission computer tomography (SPECT) performed during phrenic nerve stimulation revealed focal neuronal activation in the somatosensory pathways. Intravenously administered Tc-99m Ethyl Cysteinnate Dimmer (ECD) was used as a blood flow tracer to obtain baseline and activated images. After image registration, baseline images were compared voxel-by-voxel with the activation images. The mean inter-subject summation image of the activated state was compared with that of the baseline state using ten normal subjects. The extent of the total voxel volume increase on the mean images of the 3 activated SPECT images was 0.7%, and a mean signal increase of 22%. For further anatomic localization of regional increases in signal, the magnetic resonance image (MRI) scan of each subject was registered and superimposed on the activated stage SPECT image. This method may be used clinically to study the pathophysiology of impaired central respiratory drive.

The authors report a case of a 71-year-old man who developed myoclonic status epilepticus and coma after daily ingestion of colloidal silver for 4 months resulting in high levels of silver in plasma, erythrocytes, and CSF. Despite plasmapheresis, he remained in a persistent vegetative state until his death 5.5 months later. Silver products can cause irreversible neurologic toxicity associated with poor outcome.

Encephalopathy and polyneuropathy occur in 70% of septic patients. The encephalopathy is diffuse, appears early, is often severe, but reverses quickly with successful treatment of the sepsis. The electroencephalogram is a sensitive indicator of the incidence and severity of the encephalopathy, but computed tomograms of the brain and cerebrospinal fluid findings are unremarkable. Critical-illness polyneuropathy develops later and in association with multiple-organ failure. Recovery is more gradual. Difficulty in weaning from the ventilator is an important early manifestation. Electromyography should be routinely performed to establish the diagnosis. The polyneuropathy is a primary axonal degeneration, predominantly of distal motor fibers. A persistent deficit may eventuate in severe cases. Whether muscle is affected as consistently as brain and peripheral nerve, and by the same process, has not been determined. Medications used in critical care units, notably sedatives and neuromuscular blocking agents, often confuse the clinical picture. The neurological pathophysiology is unknown but current evidence suggests that nervous system dysfunction arises through the same mechanisms as for systemic organs in the septic syndrome.

Forty-three patients who had sepsis and multiple organ failure (critical illness) were studied prospectively to determine the incidence and severity of peripheral nerve function and to correlate such function with a number of variables. Electrophysiologic studies indicated a primary axonal degeneration of motor and sensory fibers in 30 (70 percent). Fifteen (30 percent) had the clinical signs of difficulty in weaning from assisted ventilation, weakness of limb muscles, and reduced or absent deep tendon reflexes. Full recovery from the polyneuropathy occurred among the 23 (53 percent) who survived, except three who had a very severe polyneuropathy. A peripheral nerve function index, computed from electrophysiologic measurements, showed statistically significant (p less than 0.01) negative correlations with the time in the critical care unit, and the serum glucose value; the serum albumin level showed a positive correlation. Multiple regression analyses indicated all three factors accounted for 47 percent (r2 = 0.4678) of all potential variables. In a separate analysis, the nerve function index correlated with the amplitude of the diaphragm compound muscle action potential (p less than 0.01). The results were consistent with the polyneuropathy being due to the same mechanisms that are currently postulated to cause dysfunction in this syndrome of other organ systems (including the neuromuscular respiratory system).

Objective: To systematically review outcomes in comatose survivors after cardiac arrest and cardiopulmonary resuscitation (CPR). Methods: The authors analyzed studies (1966 to 2006) that explored predictors of death or unconsciousness after 1 month or unconsciousness or severe disability after 6 months. Results: The authors identified four class I studies, three class II studies, and five class III studies on clinical findings and circumstances. The indicators of poor outcome after CPR are absent pupillary light response or corneal reflexes, and extensor or no motor response to pain after 3 days of observation (level A), and myoclonus status epilepticus (level B). Prognosis cannot be based on circumstances of CPR (level B) or elevated body temperature (level C). The authors identified one class I, one class II, and nine class III studies on electrophysiology. Bilateral absent cortical responses on somatosensory evoked potential studies recorded 3 days after CPR predicted poor outcome (level B). Burst suppression or generalized epileptiform discharges on EEG predicted poor outcomes but with insufficient prognostic accuracy (level C). The authors identified one class I, 11 class III, and three class IV studies on biochemical markers. Serum neuron-specific enolase higher than 33 μg/L predicted poor outcome (level B). Ten class IV studies on brain monitoring and neuroimaging did not provide data to support or refute usefulness in prognostication (level U). Conclusion: Pupillary light response, corneal reflexes, motor responses to pain, myoclonus status epilepticus, serum neuron-specific enolase, and somatosensory evoked potential studies can reliably assist in accurately predicting poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest.

Editors' Note: The 1994 guidelines for the diagnosis of the vegetative state (VS) should be revised, Young and Owen suggest. Estraneo et al. agree, pointing to the development of new, advanced tools that improve recognition of discernible intentional responses in patients with prolonged anoxic VS. Some corrections and interesting additions to the historical article on cerebral PET scanning are made by Singhal. Okun et al. agree and explain the challenge of word count limit. Chafic Karam, MD, and Robert C. Griggs, MD # {#article-title-2} Estraneo et al.1 prospectively …

About 40% of patients with cardiac arrest can be resuscitated with restoration of spontaneous circulation and respiration. The overall 1 year survival rate of initially unconscious survivors resuscitated from cardiac arrest has been variably quoted to be between 10 and 25% [1, 2]. Anoxic-ischemic encephalopathy is the principal cause of mortality in at least 30–40% of those who die; only 3–10% return to their previous lifestyle, including employment [3]. Under 1% survive in a persistent vegetative state (PVS) [4]. Since primary cardiac arrest is so common, the problems of assessment and management of anoxic-ischemic encephalopathy are of great importance to the intensivist and emergency physician.

Septic encephalopathy resembles many metabolic encephalopathies and is largely reversible, although some survivors of severe septic illness may have residual cognitive problems. These deficits may relate to microscopic abnormalities in the brain that we have found at autopsy. Biochemical abnormalities are directly related to the severity of the encephalopathy. It is unlikely that organ failure accounts for the early encephalopathy, but multi-organ failure probably contributes to brain dysfunction in advanced sepsis.

Of 49 patients with nonconvulsive seizures studied with continuous EEG monitoring, the overall mortality was 33% (16/49).Of the 23 patients with nonconvulsive status epilepticus (NCSE), 13 died (mortality 57%). Individual variables significantly associated with mortality were age, presence of NCSE, seizure duration, hospital and NICU length of stay, and delay to diagnosis and etiology (acute illness versus remote symptomatic). With multivariate logistic regression, only seizure duration (p = 0.0057, OR = 1.131/hour) and delay to diagnosis (p = 0.0351, OR = 1.039/hour) were associated with increased mortality. Acute symptomatic cases could not be adequately classified as either absence, simple, or complex partial status epilepticus when the impairment of consciousness arose from the initial illness. Current classifications of status epilepticus are inadequate for such cases.NEUROLOGY 1996;47: 83-89

In the study of Crepeau et al.,1 there are several findings of interest. These include both novel and confirmatory results: 1) the EEG classification had prognostic value for favorable and unfavorable outcomes; 2) patients with electrographic reactivity were much more likely to recover consciousness than those who did not; 3) the EEG can vary and this can yield prognostic information; 4) all 5 patients with seizures died; 5) episodic low-amplitude events, essentially a burst-suppression pattern, did not have the sinister prognosis that had been found in earlier studies where hypothermia was not used.

Objective: To develop a method for automatically detecting non-convulsive seizures in ICU. Background Seizures are found in at least 8% of ICU patients; of these, 50-100% have only non-convulsive seizures detectable only by continuous EEG monitoring. Non-convulsive seizure duration and delay to treatment have been shown to be associated with increased mortality [1]. Seizure detection and management is problematic: a skilled electroencephalographer is not always available, generating a need for an automated seizure detection system. Design/Methods: Using a database of 179 ICU patients undergoing continuous EEG (148d) monitoring, we have developed a method that quantifies seizure-related evolution in a two-dimensional feature space consisting of EEG frequency and power. The method was evaluated in an independent data set of 53 ICU and epilepsy monitoring unit (EMU) patients (50d) [2]. All data were analyzed by an experienced electroencephalographer (BY), who marked the onsets and offsets of ten first seizures in each recording using commonly accepted seizure criteria [1]. Seizure detection was classified successful, if it took place within 15 minutes of the first marked seizure. Results: 10/19 seizure patients of the development data set were detected (false positive rates (FPR): median 0.00/hour, mean 0.34/hour). In the evaluation data set 6/8 seizure patients were detected (FPRs: 0.06/hour, 0.52/hour). Undetected patients were either in status epilepticus (SE) or had no seizures with evolutionary characteristics. Most false detections were caused by EMG. Conclusions: The method demonstrates good potential in detecting seizures with evolution, which further can be visualized in 2-D plane, facilitating seizure recognition at the bedside. To cover the full range of seizure disorders, the method needs to be integrated with methods suitable for spike detection and SE monitoring, such as WSE [3]. Further work will focus also on reducing FPR. Supported by: GE Healthcare, Finland OY. Disclosure: Dr. Tanner has received research support from GE Healthcare. Dr. Sarkela has received research support from GE Healthcare. Dr. Tolonen has received personal compensation for activities with GE Healthcare as an employee. Dr. Norton has nothing to disclose. Dr. Davies-Schinkel has nothing to disclose. Dr. Sharpe has nothing to disclose. Dr. Young has nothing to disclose.

Ipsilateral third nerve palsy with early pupillary enlargement is an important sign of transtentorial herniation from a supratentorial mass lesion. A case of frontal, intraparenchymal haemorrhage is reported in which the first ocular manifestation of transtentorial herniation was enlargement of the contralateral pupil. The ipsilateral pupil dilated only after complete oculomotor palsy of the contralateral eye. After partial frontal lobectomy and removal of blood clot, the ipsilateral third nerve recovered before the contralateral third nerve. Clinical findings localised the contralateral third nerve lesion to an extra-axial site. The possible mechanisms of contralateral third nerve compression are discussed. This seems to be the first example of pupillary enlargement as a false localising sign from a contralateral, supratentorial, intraparenchymal mass lesion.

Effect of Continuous Infusion of Morphine on the Electroencephalogram of Infants, Admitted to a Neonatal Intensive Care Unit

We report 11 adults who exhibited myoclonic status epilepticus (MSE) after cardiac arrest. Based on pathologic, electroencephalographic, and clinical evidence, we conclude that our patients died from the initial anoxic-ischemic insult rather than as a result of MSE. We suggest that the seizures in these nonsurvivors were self-limited events arising from lethal damage to neurons. Thus, in patients with bilaterally synchronous facial myoclonus, bilateral loss of pupillary or oculovestibular reflexes, and suppression and burst-suppression on EEG, it is not warranted to use anesthetic barbiturates to treat MSE.

The Edinburgh Breast Screening Clinic in its first year completed the initial screening examination of 3005 invited women, who were apparently in good health, aged between 40 and 60 years; 141 were referred for a surgical opinion; 70 women ultimately underwent biopsy and 9 proved to have carcinoma. The indications for biopsy are described together with methods of management of the various lesions.

Myo-inositol was given orally to nine multiple sclerosis patients and nine healthy control subjects. Pattern reversal evoked potential testing was used to assess its effect. The principal positive wave increased in amplitude, duration and area in a dose-dependent manner in the multiple sclerosis group compared with controls. Cerebrospinal fluid concentrations of myo-inositol in multiple sclerosis and controls were similar. The significance of these observations is discussed in relation to recent discoveries in inositol phospholipid function.

The principal ultrasonic signs of death of the fetus in the first 12 weeks of pregnancy are reviewed and illustrated. Several new signs, one probably due to CO2 in the conceptus, are recorded. The use of two-dimensional B scanning and multiplanar stereoscopic sonar is made.

The author describes a method of identifying and measuring the fetal biparietal diameter ultrasonically, based on an anatomical pattern. This pattern takes the form of an arrow whose components lie in both the sagittal and coronal planes. It is a practical method of obtaining adequate and consistent biparietal measurements in both A/B-scan and real-time modes; in 100 patients studied both ways, the mean difference was 0.0632 mm.

1. A case of duplication of the stomach followed over a period of 23 years is described. 2. Radiological evidence of peptic ulceration in the wall of the duplication is recorded. 3. Aspects of the aetiology, symptomatology and treatment of this rare condition are discussed.

The effects of inbreeding of the sow and plane of nutrition after mating on litter size at 28 days were investigated.Outbred Large White sows were mated at first heat after weaning to inbred boars, and inbred sows to outbred boars, so that both groups of sows carried the same type of embryo. The sows were then placed at random on either high or low planes of nutrition until slaughter 28 days later, when their corpora lutea and number of embryos were counted.Litter size was significantly higher in outbred than in inbred sows by 2·52 ± 0·93 pigs. This resulted from 2·89 ± 0·94 more ova shed and 0·37 ± 0·93 more embryos dying. The general conclusion is that inbreeding of the sow reduces early litter size mainly by depressing ovulation rate.The different planes of nutrition produced negligible differences in within-litter mortality and, therefore, on litter size, but resulted in a marked difference in conception rate. All animals on the high plane were pregnant, whereas on the low plane 25% were empty, this difference being highly significant.Age of the sow, but not her weight, was found to be significantly correlated with number of corpora lutea (r = 0·39). The latter had a correlation with litter size of 0·55 and with mortality of 0·45. The correlation between litter size and mortality was −0·50.Parity increased and inbreeding reduced the length of the uterus which was not, however, significantly correlated with litter size.

With the increasing use of mammography in the diagnosis and follow-up of breast cancer, the question of radiation hazard has become of considerable interest (Ostrum, Becker and Isard, 1973; Samuel, 1973). There can be no doubt that ionizing radiation, given in sufficient quantity, is carcinogenic. There is evidence in a number of clinical reports (MacKenzie, 1965; Myrden and Hiltz, 1969; Mettler, 1969; Mole, 1973; Wanebo et al., 1968) as well as additional evidence from experimental work (Shellabargar et al., 1957). Whether one or two sets of mammograms are sufficient to induce malignant change in a breast is more doubtful. However, in problem cases of breast disease, and in screening procedure for breast cancer where yearly mammograms are the custom, irradiation of the breast can mount up rapidly, and apparently dangerous levels of radiation can be reached. Such levels can be greatly reduced if the rads per exposure are kept low (Young, 1974). There has been speculation on the probable increased incidenc...

Three hundred cases in which both ultrasonic and soft tissue placentography examinations had been done are correlated with each other and the clinical findings. These are grouped in two series, one in 1972-1973 and the other 1973-1974. The accuracy rate for both methods was 95 per cent. Outright errors were 2 per cent, and cases in which correlation was lacking for reasons other than diagnostic errors were 3 per cent. Reasons for this lack of correlation are discussed and illustrated. Seven examples of the ascending (or migrating) placenta were also found and an illustrative case is described.

The application of ultrasound to measure Graafian follicle growth in spontaneous and induced ovular menstrual cycles in women has been described by Hackloer et al.1,2 and ylostalo et al.3 They were able to demonstrate a good correlation between incremental follicular growth and increasing oestrogen levels in peripheral venous blood. Their methods were adopted to measure the daily follicular growth in the ovaries of women undergoing donor artificial insemination(AID) with cryopreserved semen. Preliminary results have been described4: It was found that insemination could be timed to the day before and the day of rupture of the dominant Graafian follicle with a considerable degree of precision. There is increasing evidence that these are the optimal days for insemination in a menstrual cycle if the lowest cycle to conception ratio (recognizable fecundability) is to be achieved.5

The daily growth rates of ovarian follicles were recorded ultrasonically for five days until ovulation in 56 spontaneously ovulating women and related to endocrine and clinical parameters. Over the 5-day period, the average diameter of the follicle destined to ovulate increased from 12 to 23 mm, the second largest follicle from 6 to 12 mm, the third largest follicle from 5 to 9 mm and the fourth largest follicle from 4 to 8 mm. Similar but lesser growth rates occurred in the follicles in the contralateral ovary. Ovulation occurred within 24 hours of the luteinizing hormone (LH) peak, and the mean peak diameter of the ovulating follicle was 23.2 +/- 0.3 (SEM) mm, (range 18-29 mm) before ovulation, and subsequent luteal function was judged to be normal. Follicular growth was most closely correlated with increasing peripheral blood oestrogen levels. In 16 women who had a laparoscopy within 12 hours of the last ultrasound and following the LH peak, the mean diameter of the largest follicle as measured by ultrasound (23.6 +/- 0.4 mm) was similar to that measured at laparoscopy (22.8 +/- 0.04 mm) and estimated from the volume of follicular fluid aspirated (average 5.8 +/- 0.2 ml), 22.5 mm. The follicular fluid levels of progesterone were high on the day of the LH peak and blood progesterone levels had risen significantly indicating that luteinization of the dominant Graafian follicles had already occurred prior to ovulation. This study confirms that ultrasonic monitoring provides a reliable measure of follicular growth and allows studies correlating morphological changes with both normal and abnormal endocrine function of the human ovary.

Human lymphocytes and Chinese hamster ovary (CHO) cells in culture were exposed for 12 1/2 hours to a magnetic resonance imaging apparatus with a 2.35-Tesla magnet and 100-MHz radio frequency emission. The cells were examined for cytogenetic damage manifested either as chromosome aberrations or sister chromatid exchanges (SCEs), which constitute very sensitive measures of genetic and cellular damage. In either unstimulated or stimulated human lymphocytes, as well as in exponentially growing CHO cells, no increase in either chromosome aberrations or SCEs was found as a result of exposure to these MR conditions. The data indicate that long-term exposure to MR imaging conditions far exceeding those to be found in the clinical situation does not cause cytogenetic damage.

To obtain satisfactory mammograms kilovoltages of below 35 must be used. At higher levels the difference of absorption between the fat, connective tissue and glandular parenchyma of the breast is so small that adequate contrast is not attained (Siler, Snyder, Garrett, Laughlin and Sherman, 1964; Stanton, Lightfoot, Boyle and Cullinan, 1963). Whether industrial or standard unscreened film gives the best results is still debated. Added detail at the expense of added irradiation is undoubtedly obtained by the use of industrial film (Egan, 1964), but satisfactory contrast can be achieved by the use of both types of film (Curcio, 1962). The controversy would appear to be largely a question of personal preference and usage.

To the Editor: —In the report of the transactions of the House of Delegates at Atlantic City (The Journal, June 15, p. 1904), appears the report submitted by the Committee on National Public Health Legislation. The report is signed by various members of the committee, but my signature does not appear. The explanation of this is that I was not consulted in regard to the contents of the report, was not permitted to see it before it was transmitted, and consequently had no opportunity so sign it. Of course, this is more a matter of importance from the standpoint of good manners, both official and personal, than it is of ethics, and therefore hardly worth while being concerned about, but inasmuch as the House of Delegates conferred on me the honor of designating me as a member of the national committee, I deem it proper to explain to the members

In the fall of 1913 the department for the first time published a complete handbook for the bureau of medical inspection, and in that connection made quite extensive changes in the methods hitherto employed in connection with quarantine. Owing to unavoidable delays in connection with the budget, etc., the changes were not put fully into effect until March 15, 1914. Our experience with classified quarantine from March 15 to November 1 has been quite instructive. As a preliminary explanation let me give a summary of the methods of quarantine now enforced by the department. The result sought is to avoid the imposition of all restraint upon the family of the patient when consistent with effective isolation of the patient and "carriers," the object being, in brief, to quarantine the public out and to quarantine the patient in. To this end the following rules will be enforced: A.—Isolation with Trained Attendant

Cooling of the skin over the medial supraorbital region in 80% of patients who have an occlusion or severe stenosis of a carotid artery can be demonstrated by facial thermography. Minor stenotic lesions in the carotid arteries do not produce characteristic thermographic changes, while thermography is of no help in the diagnosis of vertebrobasilar arterial disease. Thermographic changes suggestive of carotid arterial lesions are found occasionally in patients whose angiograms are normal, owing to variations in the size of the frontal sinuses, or factors such as fever or inflammatory lesions. It is suggested that facial thermography is of value in the preliminary investigation of patients with occlusive cerebrovascular disease.