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Abstract
Objective To analyze the association between peri-ictal brainstem posturing semiologies with postictal generalized electroencephalographic suppression (PGES) and breathing dysfunction in generalized convulsive seizures (GCS).
Methods In this prospective, multicenter analysis of GCS, ictal brainstem semiology was classified as (1) decerebration (bilateral symmetric tonic arm extension), (2) decortication (bilateral symmetric tonic arm flexion only), (3) hemi-decerebration (unilateral tonic arm extension with contralateral flexion) and (4) absence of ictal tonic phase. Postictal posturing was also assessed. Respiration was monitored with thoracoabdominal belts, video, and pulse oximetry.
Results Two hundred ninety-five seizures (180 patients) were analyzed. Ictal decerebration was observed in 122 of 295 (41.4%), decortication in 47 of 295 (15.9%), and hemi-decerebration in 28 of 295 (9.5%) seizures. Tonic phase was absent in 98 of 295 (33.2%) seizures. Postictal posturing occurred in 18 of 295 (6.1%) seizures. PGES risk increased with ictal decerebration (odds ratio [OR] 14.79, 95% confidence interval [CI] 6.18–35.39, p < 0.001), decortication (OR 11.26, 95% CI 2.96–42.93, p < 0.001), or hemi-decerebration (OR 48.56, 95% CI 6.07–388.78, p < 0.001). Ictal decerebration was associated with longer PGES (p = 0.011). Postictal posturing was associated with postconvulsive central apnea (PCCA) (p = 0.004), longer hypoxemia (p < 0.001), and Spo2 recovery (p = 0.035).
Conclusions Ictal brainstem semiology is associated with increased PGES risk. Ictal decerebration is associated with longer PGES. Postictal posturing is associated with a 6-fold increased risk of PCCA, longer hypoxemia, and Spo2 recovery. Peri-ictal brainstem posturing may be a surrogate biomarker for GCS severity identifiable without in-hospital monitoring.
Classification of Evidence This study provides Class III evidence that peri-ictal brainstem posturing is associated with the GCS with more prolonged PGES and more severe breathing dysfunction.
Glossary
- CI=
- confidence interval;
- EST=
- β estimate;
- GCS=
- generalized convulsive seizures;
- GEE=
- generalized estimating equation;
- ICA=
- ictal central apnea;
- MORTEMUS=
- Mortality in Epilepsy Monitoring Unit Study;
- OR=
- odds ratio;
- PAG=
- periaqueductal gray;
- PCCA=
- postconvulsive central apnea;
- PGES=
- postictal generalized electroencephalographic suppression;
- PRISM=
- Prevention and Risk Identification of SUDEP Mortality;
- SUDEP=
- sudden unexpected death in epilepsy;
- VEEG=
- video-EEG
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Editorial, page 89
Class of Evidence: NPub.org/coe
- Received August 18, 2019.
- Accepted in final form August 17, 2020.
- © 2020 American Academy of Neurology
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