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November 06, 2012; 79 (19) Articles

Generalized periodic discharges in the critically ill

A case-control study of 200 patients

Brandon Foreman, Jan Claassen, Karine Abou Khaled, Jeffrey Jirsch, Daniel M. Alschuler, John Wittman, Ronald G. Emerson, Lawrence J. Hirsch
First published October 3, 2012, DOI: https://doi.org/10.1212/WNL.0b013e3182735cd7
Brandon Foreman
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Jan Claassen
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Karine Abou Khaled
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Jeffrey Jirsch
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Daniel M. Alschuler
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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John Wittman
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Ronald G. Emerson
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Lawrence J. Hirsch
From the Comprehensive Epilepsy Center (B.F.), Division of Critical Care Neurology (J.C.), Neurological Institute of New York, Columbia University, New York; Hotel-Dieu De France (K.A.K.), Universite Saint-Joseph, Lebanon; Department of Medicine (Division of Neurology) (J.J.), University of Alberta, Edmonton, Canada; Cognitive Neuroscience Division (D.M.A.), New York State Psychiatric Institute, New York; Neurological Associates, Inc. (J.W.), Henrico, VA; Intraoperative Neurophysiologic Monitoring (R.G.E.), Hospital for Special Surgery, New York, NY; and Division of Epilepsy/EEG (L.J.H.), Yale University School of Medicine, New Haven, CT.
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Citation
Generalized periodic discharges in the critically ill
A case-control study of 200 patients
Brandon Foreman, Jan Claassen, Karine Abou Khaled, Jeffrey Jirsch, Daniel M. Alschuler, John Wittman, Ronald G. Emerson, Lawrence J. Hirsch
Neurology Nov 2012, 79 (19) 1951-1960; DOI: 10.1212/WNL.0b013e3182735cd7

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Abstract

Objective: Generalized periodic discharges are increasingly recognized on continuous EEG monitoring, but their relationship to seizures and prognosis remains unclear.

Methods: All adults with generalized periodic discharges from 1996 to 2006 were matched 1:1 to controls by age, etiology, and level of consciousness. Overall, 200 patients with generalized periodic discharges were matched to 200 controls.

Results: Mean age was 66 years (range 18–96); 56% were comatose. Presenting illnesses included acute brain injury (44%), acute systemic illness (38%), cardiac arrest (15%), and epilepsy (3%). A total of 46% of patients with generalized periodic discharges had a seizure during their hospital stay (almost half were focal), vs 34% of controls (p = 0.014). Convulsive seizures were seen in a third of both groups. A total of 27% of patients with generalized periodic discharges had nonconvulsive seizures, vs 8% of controls (p < 0.001); 22% of patients with generalized periodic discharges had nonconvulsive status epilepticus, vs 7% of controls (p < 0.001). In both groups, approximately half died or were in a vegetative state, one-third had severe disability, and one-fifth had moderate to no disability. Excluding cardiac arrest patients, generalized periodic discharges were associated with increased mortality on univariate analysis (36.8% vs 26.9%; p = 0.049). Multivariate predictors of worse outcome were cardiac arrest, coma, nonconvulsive status epilepticus, and sepsis, but not generalized periodic discharges.

Conclusion: Generalized periodic discharges were strongly associated with nonconvulsive seizures and nonconvulsive status epilepticus. While nonconvulsive status epilepticus was independently associated with worse outcome, generalized periodic discharges were not after matching for age, etiology, and level of consciousness.

GLOSSARY

AED=
antiepileptic drug;
BIPLED=
bilateral independent periodic discharge;
CA=
cardiac arrest;
cEEG=
continuous digital EEG monitoring;
cIV=
continuous IV;
CJD=
Creutzfeldt-Jakob disease;
CSE=
convulsive status epilepticus;
CSz=
convulsive;
ED=
emergency department;
GOS=
Glasgow Outcome Scale;
GPD=
generalized periodic discharge;
ICU=
intensive care unit;
NCSE=
nonconvulsive status epilepticus;
NCSz=
nonconvulsive;
PLED=
periodic lateralized epileptiform discharge;
SE=
status epilepticus;
SIRPID=
stimulus-induced rhythmic, periodic, or ictal discharge;
SSPE=
subacute sclerosing panencephalitis;
TW=
triphasic-appearing wave

Footnotes

  • Editorial, page 1940

  • Supplemental data at www.neurology.org

  • Received March 6, 2012.
  • Accepted July 6, 2012.
  • Copyright © 2012 by AAN Enterprises, Inc.
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