EEG Artifact Versus Subclinical Status Epilepticus in a Patient Following Cardiac Arrest

  • Jean E. Cibula
  • Daniel S. Demos
  • Brenda G. Fahy
Neuroimage

Abstract

Background

A challenge in ICU EEG interpretation is identifying subclinical status epilepticus versus patterns on the ictal–interictal continuum versus other repetitive patterns. In the electrically noisy intensive care unit, identifying and eliminating interference and artifact allow accurate diagnoses from the EEG, avoiding unnecessary treatment or sedation.

Methods

We present a case during Impella (Abiomed Inc, Danvers, MA) continuous flow left ventricular assist device use where the EEG artifact was initially misinterpreted as seizure by the resident and treated as status epilepticus because of the “focal” sharply contoured repetitive pattern. During percutaneous coronary intervention (PCI), an 88-year-old developed ventricular tachycardia followed by ventricular fibrillation requiring chest compressions for 10 min, multiple defibrillations, and treatment with epinephrine, amiodarone, calcium, bicarbonate, and magnesium. The patient had an Impella placed during PCI with therapeutic hypothermia initiated after the cardiopulmonary arrest. His neurological exam demonstrated preserved pupillary, corneal, gag and cough reflexes and spontaneous respirations.

Results

Long-term video EEG monitoring is included in our institution’s hypothermia protocol. Initial baseline EEG performed 2 h after PCI showed a persistent rhythmic sharp discharge from the left central temporal region resembling left hemisphere status epilepticus. The sharp waves have an alternating repeating 2:1 relationship with the EKG rhythm strip. This is best seen in the left hemisphere, which we posit is related to the Impella’s positioning across the aortic valve pointing toward the patient’s left side. A chest x-ray confirmed the device’s position immediately before EEG monitoring. Arterial pressure tracings were not available in the chart.

Conclusions

There is a low-amplitude spiky artifact; however, there was no pacing at that time. It is possible that synergistic flow with systole/diastole reinforced the pulsatility with movement of the Impella, resulting in the alternating pattern. The patient’s hemodynamic instability precluded extensive troubleshooting with the Impella device, but after EEG repositioning, the artifact was eliminated.

Keywords

EEG artifact Device artifact ICU EEG 

Notes

Acknowledgements

Dr. Cibula is Site PI on a study funded by SAGE Therapeutics (Protocol # 547-SSE-301) entitled “A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of SAGE-547 Injection in the Treatment of Subjects with Super-Refractory Status Epilepticus.” Dr. Demos reports no disclosures. Dr. Fahy is co-investigator on a study funded by SAGE Therapeutics (Protocol # 547-SSE-301) entitled “A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of SAGE-547 Injection in the Treatment of Subjects with Super-Refractory Status Epilepticus.”

Author Contributions

JC assisted with the study concept and design and revising the report for intellectual content. DD assisted with drafting the report. BGF assisted with the study concept and design, drafting and revising the report for intellectual content.

References

  1. 1.
    Chong DJ, Hirsch LJ. Which EEG patterns warrant treatment in the critically ill? Reviewing the evidence for treatment of periodic epileptiform discharges and related patterns. J Clin Neurophysiol. 2005;22(2):79–91.CrossRefPubMedGoogle Scholar
  2. 2.
    Tatum WO, Dworetzky BA, Schomer DL. Artifact and recording concepts in EEG. J Clin Neurophysiol. 2011;28(3):252–63.CrossRefPubMedGoogle Scholar
  3. 3.
    Saffarzadeh A, Bonde P. Options for temporary mechanical circulatory support. J Thorac Dis. 2015;7(12):2102–11.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Florida College of MedicineGainesvilleUSA
  2. 2.Department of AnesthesiologyUniversity of Florida College of MedicineGainesvilleUSA
  3. 3.Department of AnesthesiologyUniversity of Florida College of MedicineGainesvilleUSA

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