Bradley J. Kolls

Diagnostic Accuracy of Electrographic Seizure Detection by Neurophysiologists and Non-Neurophysiologists in the Adult ICU Using a Panel of Quantitative EEG Trends.

Purpose: To evaluate the sensitivity and specificity of a panel of quantitative EEG (qEEG) trends for seizure detection in adult intensive care unit (ICU) patients when reviewed by neurophysiologists and non-neurophysiologists. Methods: One hour qEEG panels (n = 180) were collected retrospectively from 45 ICU patients and were distributed to 5 neurophysiologists, 7 EEG technologists, and 5 Neuroscience ICU nurses for evaluation of seizures. Each panel consisted of the following qEEG tools, displayed separately for left and right hemisphere electrodes: rhythmicity spectrogram (rhythmic run detection and display; Persyst Inc), color density spectral array, EEG asymmetry index, and amplitude integrated EEG. The reviewers did not have access to the raw EEG data. Results: For the reviewers ability to detect the presence of seizures on qEEG panels when compared with the gold standard of independent raw EEG review, the sensitivities and specificities are as follows: neurophysiologists 0.87 and 0.61, EEG technologists 0.80 and 0.80, and Neuroscience ICU nurses 0.87 and 0.61, respectively. There was no statistical difference among the three groups regarding sensitivity. Conclusions: Quantitative EEG display panels are a promising tool to aid detection of seizures by non-neurophysiologists as well as by neurophysiologists. However, even when used as a panel, qEEG trends do not appear to be adequate as the sole method for reviewing continuous EEG data.

Endovascular treatment of venous sinus thrombosis: a case report and review of the literature

Dural venous sinus thrombosis (DVST) is a pathological phenomenon resulting from vascular occlusion of the cerebral venous sinuses. The mainstay of therapy for DVST is anticoagulation but more aggressive interventional therapies must be considered when medical therapy fails. A case is presented of a patient who was diagnosed with DVST, medically treated immediately but continued to deteriorate. Invasive endovascular therapies ultimately obliterated the thrombi in her sinuses. A brief review of the literature is reported.

Neuroprotective pentapeptide CN-105 is associated with reduced sterile inflammation and improved functional outcomes in a traumatic brain injury murine model

At present, there are no proven pharmacological treatments demonstrated to improve long term functional outcomes following traumatic brain injury(TBI). In the setting of non-penetrating TBI, sterile brain inflammatory responses are associated with the development of cerebral edema, intracranial hypertension, and secondary neuronal injury. There is increasing evidence that endogenous apolipoprotein E(apoE) modifies the neuroinflammatory response through its role in downregulating glial activation, however, the intact apoE holoprotein does not cross the blood-brain barrier due to its size. To address this limitation, we developed a small 5 amino acid apoE mimetic peptide(CN-105) that mimics the polar face of the apoE helical domain involved in receptor interactions. The goal of this study was to investigate the therapeutic potential of CN-105 in a murine model of closed head injury. Treatment with CN-105 was associated with a durable improvement in functional outcomes as assessed by Rotarod and Morris Water Maze and a reduction in positive Fluoro-Jade B stained injured neurons and microglial activation. Administration of CN-105 was also associated with reduction in mRNA expression of a subset of inflammatory and immune-related genes.

Apolipoprotein E mimetic peptide CN-105 improves outcome in a murine model of SAH

Objective Subarachnoid haemorrhage (SAH) accounts for 3% of all strokes, and is associated with significant morbidity and mortality. There is growing evidence implicating apolipoprotein E (apoE) in mediating adaptive anti-inflammatory and neuroprotective responses following ischaemic and traumatic brain injury. In the current study, we test the efficacy of a small apoE mimetic peptide, CN-105 in a murine model of SAH. Methods Mice subjected to SAH received repeated intravenous injections of CN-105 every 12 hours for 3 days, with the first dose given 2 hours after injury. Daily functional outcomes were assessed by rotarod and neurological severity score. Haemorrhage grade and cerebral vascular diameters were measured at 5 days post-SAH. Cerebral microgliosis, neuronal degeneration and survival were analysed at 5 and 35 days post-SAH, respectively. Results CN-105 reduces histological evidence of inflammation, reduces vasospasm and neuronal injury and is associated with improved long-term behavioural outcomes in a murine model of SAH. Conclusions Given its favourable pharmacokinetic profile, central nervous system penetration and demonstration of clinical safety, CN-105 represents an attractive therapeutic candidate for treatment of brain injury associated with SAH.

S20. EEG features of nonconvulsive seizures in critically ill patients - Findings from the TRENdS trial

Introduction There is little data on the EEG features of seizures seen critically ill patients having nonconvulsive seizures (NCS). The Treatment of Recurrent Electrographic Nonconvulsive Seizures (TRENdS) study enrolled 74 such subjects and randomized them to treatment with lacosamide or fosphenytoin. This study evaluates the EEG features of a subset of these subjects. Methods EEG features of 36 of the 74 subjects enrolled in the TRENdS study were analyzed in detail. The extent of spread, onset frequency, offset frequency and morphology of the most common seizure type was assessed. Results In this cohort, the average number of seizures per subject was 35.9 (range 1–339). Seizures were limited to one quadrant (11, 30.6%) or hemispheric (11, 30.6%) in most subjects. Another 14 (38.8%) subjects had seizures that were generalized, bilateral but not generalized or spread to varying extent. Most subjects had seizures with delta frequency onset (18, 50%), while another 9 (25%) had theta frequencies at onset. Another 9 (25%) subjects had seizure onset frequencies in alpha or beta range, or had seizures with varying onset frequencies. At seizure termination, delta frequencies were noted in 29 (80.6%) subjects, while 7 (19.4%) had various other frequencies. The morphology of the seizures was a rhythmic discharge in 17 (47.2%) subjects, recurrent spike or sharp discharges in 5 (13.9%), recurrent spike and wave discharges in 5 (13.9%) and various other morphologies in 9 (25%) others. Conclusion NCS in this cohort of subjects were mostly limited to one hemisphere. The seizure onset frequencies were most often in the delta and theta range, while delta frequencies were noted most often at offset. Rhythmic discharges were the most common morphology.

Randomized trial of lacosamide versus fosphenytoin for nonconvulsive seizures: Lacosamide vs Fosphenytoin

The optimal treatment of nonconvulsive seizures in critically ill patients is uncertain. We evaluated the comparative effectiveness of the antiseizure drugs lacosamide (LCM) and fosphenytoin (fPHT) in this population.

Understanding P values

8 l Nursing2011CriticalCare l Volume 6, Number 6 www.nursing2011criticalcare.com LLas Vegas. It was hot. It was dry. My daughter, Natalie, had decided that getting married in Las Vegas was lucky, and she choose July 7, 2007 (7/7/07) as the luckiest day to get married. This unique idea was shared by just over 3,000 other couples. As we rode from our hotel to the chapel, Natalie informed me that after the wedding, she was going to celebrate by playing roulette. As any good father would, I cautioned against this, but she insisted that she had a system. In fact, she said she’d tested this system yesterday (without playing her money) and after four spins, betting only on red or black, she would already have quadrupled her money. Unfortunately, she was a newlywed with no money of her own. So she offered me an opportunity. She’d play roulette with my money, and we’d split the winnings. She pleaded, “Daddy, with just one spin of the wheel, we could double our money.” Yup, they always call you daddy when they want something...and when did my life savings become “our money”? Readers, would you take this bet? Let’s assume that there are two options to every spin of the roulette wheel: The ball may land on red or it may land on black. Would you trust Natalie’s system and bet your life savings on one spin of the wheel? As nurses, we essentially gamble with our patients’ health: We bet that a patient will do better if we administer certain medications. What’s the level of evidence that we, as nurses, require before we reject the idea that our patient has just as good a chance at recovering even if we don’t give them the medication? I made the decision that before I took my money to the table, I should design an experiment to test the accuracy of Natalie’s system. The roulette wheel has two options (red or black)—a dichotomous response—the same as tossing a coin. I could test the hypothesis that the system was better than just taking a chance by testing its ability to correctly predict the outcome of a coin toss. In scientific terms, the null hypothesis is that Natalie’s system is no different than chance and chance alone. You may recognize the form for expressing the null and alternate hypotheses from previous courses in nursing research. • The null hypothesis (HO): System = chance • The alternate hypothesis (HA) System > chance. I took a quarter out my pocket, tossed it high into the air, and asked Natalie, “Heads or tails?” As I tossed the coin for the first time, I knew that on each toss, two results were possible: Natalie could be right (R), or she could be wrong (W). In The first toss you see that if the coin is heads and her “system” predicts heads, then she’s right (R), and if the “system” predicts tails, she’s wrong (W). Most people correctly identify that Natalie has a 50/50 chance of being right. Mathematically we can express this as probability (P). With one toss of the coin, the probability of being right is equal to the probability of being wrong. Understanding P values