Objective To characterize the risk for seizures over time in relation to EEG findings in hospitalized adults undergoing continuous EEG monitoring (cEEG). Methods Retrospective analysis of cEEG data and medical records from 625 consecutive adult inpatients monitored at a tertiary medical center. Using survival analysis methods, we estimated the time-dependent probability that a seizure will occur within the next 72-h, if no seizure has occurred yet, as a function of EEG abnormalities detected so far. Results Seizures occurred in 27% (168/625). The first seizure occurred early (<30 min of monitoring) in 58% (98/168). In 527 patients without early seizures, 159 (30%) had early epileptiform abnormalities, versus 368 (70%) without. Seizures were eventually detected in 25% of patients with early epileptiform discharges, versus 8% without early discharges. The 72-h risk of seizures declined below 5% if no epileptiform abnormalities were present in the first two hours, whereas 16 h of monitoring were required when epileptiform discharges were present. 20% (74/388) of patients without early epileptiform abnormalities later developed them; 23% (17/74) of these ultimately had seizures. Only 4% (12/294) experienced a seizure without preceding epileptiform abnormalities. Conclusions Seizure risk in acute neurological illness decays rapidly, at a rate dependent on abnormalities detected early during monitoring. This study demonstrates that substantial risk stratification is possible based on early EEG abnormalities. Significance These findings have implications for patient-specific determination of the required duration of cEEG monitoring in hospitalized patients.
Objective: Quantitatively evaluate whether screening with compressed spectral arrays (CSAs) is a practical and time-effective protocol for assisting expert review of continuous EEG (cEEG) studies in hospitalized adults.Methods: Three neurophysiologists reviewed the reported findings of the first 30 minutes of 118 cEEGs, then used CSA to guide subsequent review ("CSA-guided review" protocol). Reviewers viewed 120 seconds of raw EEG data surrounding suspicious CSA segments. The same neurophysiologists performed independent page-by-page visual interpretation ("conventional review") of all cEEGs. Independent conventional review by 2 additional, more experienced neurophysiologists served as a gold standard. We compared review times and detection rates for seizures and other pathologic patterns relative to conventional review.Results: A total of 2,092 hours of cEEG data were reviewed. Average times to review 24 hours of cEEG data were 8 (64) minutes for CSA-guided review vs 38 (617) minutes for conventional review (p , 0.005). Studies containing seizures required longer review: 10 (64) minutes for CSAguided review vs 44 (620) minutes for conventional review (p , 0.005). CSA-guided review was sensitive for seizures (87.3%), periodic epileptiform discharges (100%), rhythmic delta activity (97.1%), focal slowing (98.7%), generalized slowing (100%), and epileptiform discharges (88.5%).
Epilepsy is a common condition in the United States. It is estimated that 1.2% of the population or 3.4 million people have epilepsy. This figure may be underestimated because of potential repercussions and stigma in disclosing epilepsy. 1 Studies have shown that people with epilepsy are more likely to be unemployed or unable to work, have lower annual household incomes, be obese and physically inactive, and be less likely to marry. 2,3 People with epilepsy can have poor overall health status, impaired intellectual and physical functioning, elevated risk of accidents and injuries, and negative side effects from antiseizure medications. 2,3 It is estimated the annual direct medical cost of epilepsy in the United States is $9.6 billion; combined with indirect costs, the total rises to $15.5 billion yearly. 2 The American Academy of Neurology (AAN) created standardized quality measures with the overarching goal to improve the delivery of care for patients with epilepsy for providers, practices, and systems. In 2009, the first set of epilepsy measures were released with an update provided in 2014. 4,5 Quality measures are not guidelines; however, they are formed using guidelines, evidence-based medicine, and best practice consensus. Quality measures help us understand how often health care services are provided consistent with current medical knowledge. Measures are updated iteratively to reflect evidence and practice changes, as well as to reflect limitations of data collection and analysis. The AAN reviews each measurement set for updates a minimum of every 3 years. In 2017, the AAN seated a standing multidisciplinary Epilepsy Quality Measurement Set Work Group (work group) charged with updating the measurement set. This work group will revisit the epilepsy measures every 6 months, evaluating new evidence statements and new measures released by other developers. As part of this process, epilepsy measure implementation and performance data review will also occur to nimbly respond to emerging guidelines and evidence. During this initial review, the work group evaluated new evidence, 2014 epilepsy measure use data, and other new measures released by other development groups that addressed care for patients with epilepsy, such as the AAN's Child Neurology and Universal Neurology Quality Measure projects. The work group approved 6 measures and retired 6 measures from the 2014 update (table 1). Measure retirement occurs if evidence has changed, a gap in performance no longer exists, feasibility concerns exist, or significant edits are needed to the existing measure. It does not mean the topic is no longer important.
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