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Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest.

ABSTRACT: OBJECTIVE:We tested the hypothesis that there are readily classifiable electroencephalographic (EEG) phenotypes of early postanoxic multifocal myoclonus (PAMM) that develop after cardiac arrest. METHODS:We studied a cohort of consecutive comatose patients treated after cardiac arrest from January 2012 to February 2015. For patients with clinically evident myoclonus before awakening, 2 expert physicians reviewed and classified all EEG recordings. Major categories included: Pattern 1, suppression-burst background with high-amplitude polyspikes in lockstep with myoclonic jerks; and Pattern 2, continuous background with narrow, vertex spike-wave discharges in lockstep with myoclonic jerks. Other patterns were subcortical myoclonus and unclassifiable. We compared population characteristics and outcomes across these EEG subtypes. RESULTS:Overall, 401 patients were included, of whom 69 (16%) had early myoclonus. Among these patients, Pattern 1 was the most common, occurring in 48 patients (74%), whereas Pattern 2 occurred in 8 patients (12%). The remaining patients had subcortical myoclonus (n = 2, 3%) or other patterns (n = 7, 11%). No patients with Pattern 1, subcortical myoclonus, or other patterns survived with favorable outcome. By contrast, 4 of 8 patients (50%) with Pattern 2 on EEG survived, and 4 of 4 (100%) survivors had favorable outcomes despite remaining comatose for 1 to 2 weeks postarrest. INTERPRETATION:Early PAMM is common after cardiac arrest. We describe 2 distinct patterns with distinct prognostic significances. For patients with Pattern 1 EEGs, it may be appropriate to abandon our current clinical standard of aggressive therapy with conventional antiepileptic therapy in favor of early limitation of care or novel neuroprotective strategies. Ann Neurol 2016;80:175-184.

SUBMITTER: Elmer J

PROVIDER: S-EPMC4982787 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest.

Elmer Jonathan J Rittenberger Jon C JC Faro John J Molyneaux Bradley J BJ Popescu Alexandra A Callaway Clifton W CW Baldwin Maria M

Annals of neurology 20160628 2

<h4>Objective</h4>We tested the hypothesis that there are readily classifiable electroencephalographic (EEG) phenotypes of early postanoxic multifocal myoclonus (PAMM) that develop after cardiac arrest.<h4>Methods</h4>We studied a cohort of consecutive comatose patients treated after cardiac arrest from January 2012 to February 2015. For patients with clinically evident myoclonus before awakening, 2 expert physicians reviewed and classified all EEG recordings. Major categories included: Pattern ...[more]

PMID: 27351833

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Project description:OBJECTIVE:Electroencephalographic status epilepticus occurs in 9-35% of comatose patients after cardiac arrest. Mortality is 90-100%. It is unclear whether (some) seizure patterns represent a condition in which anti-epileptic treatment may improve outcome, or severe ischemic damage, in which treatment is futile. We explored current treatment practice and its effect on patients' outcome. METHODS:We retrospectively identified patients that were treated with anti-epileptic drugs from our prospective cohort study on the value of continuous electroencephalography (EEG) in comatose patients after cardiac arrest. Outcome at 6?months was dichotomized between "good" [cerebral performance category (CPC) 1 or 2] and "poor" (CPC 3, 4, or 5). EEG analyses were done at 24?h after cardiac arrest and during anti-epileptic treatment. Unequivocal seizures and generalized periodic discharges during more than 30?min were classified as status epilepticus. RESULTS:Thirty-one (22%) out of 139 patients were treated with anti-epileptic drugs (phenytoin, levetiracetam, valproate, clonazepam, propofol, midazolam), of whom 24 had status epilepticus. Dosages were moderate, barbiturates were not used, medication induced burst-suppression not achieved, and treatment improved electroencephalographic status epilepticus patterns temporarily (<6?h). Twenty-three patients treated for status epilepticus (96%) died. In patients with status epilepticus at 24?h, there was no difference in outcome between those treated with and without anti-epileptic drugs. CONCLUSION:In comatose patients after cardiac arrest complicated by electroencephalographic status epilepticus, current practice includes unstandardized, moderate treatment with anti-epileptic drugs. Although widely used, this does probably not improve patients' outcome. A randomized controlled trial to estimate the effect of standardized, aggressive treatment, directed at complete suppression of epileptiform activity during at least 24?h, is needed and in preparation.

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Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest.

Publications

Clinically distinct electroencephalographic phenotypes of early myoclonus after cardiac arrest.

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