Continuous electroencephalography predicts delayed cerebral ischemia after subarachnoid hemorrhage: A prospective study of diagnostic accuracy

Objective Delayed cerebral ischemia (DCI) is a common, disabling complication of subarachnoid hemorrhage (SAH). Preventing DCI is a key focus of neurocritical care, but interventions carry risk and cannot be applied indiscriminately. Although retrospective studies have identified continuous electroe...

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Bibliographic Details
Published in:Annals of neurology 2018-05, Vol.83 (5), p.958-969
Main Authors: Rosenthal, Eric S., Biswal, Siddharth, Zafar, Sahar F., O'Connor, Kathryn L., Bechek, Sophia, Shenoy, Apeksha V., Boyle, Emily J., Shafi, Mouhsin M., Gilmore, Emily J., Foreman, Brandon P., Gaspard, Nicolas, Leslie‐Mazwi, Thabele M., Rosand, Jonathan, Hoch, Daniel B., Ayata, Cenk, Cash, Sydney S., Cole, Andrew J., Patel, Aman B., Westover, M. Brandon
Format: Article
Language:English
Subjects:
Abnormalities
Accuracy
Adult
Aged
Alarms
Aneurysms
Brain
Brain injury
Brain Ischemia - physiopathology
Cerebral Infarction - complications
Cerebral Infarction - physiopathology
Clinical trials
Diagnostic systems
EEG
Electroencephalography
Electroencephalography - methods
Epilepsy
Female
Head injuries
Health risks
Hemorrhage
Humans
Ischemia
Latency
Male
Medical research
Middle Aged
Monitoring, Physiologic - methods
Neurology
Patients
Prospective Studies
Retrospective Studies
Risk analysis
Sensitivity
Sensitivity and Specificity
Subarachnoid hemorrhage
Subarachnoid Hemorrhage - diagnosis
Subarachnoid Hemorrhage - physiopathology
Survival analysis
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Summary:Objective Delayed cerebral ischemia (DCI) is a common, disabling complication of subarachnoid hemorrhage (SAH). Preventing DCI is a key focus of neurocritical care, but interventions carry risk and cannot be applied indiscriminately. Although retrospective studies have identified continuous electroencephalographic (cEEG) measures associated with DCI, no study has characterized the accuracy of cEEG with sufficient rigor to justify using it to triage patients to interventions or clinical trials. We therefore prospectively assessed the accuracy of cEEG for predicting DCI, following the Standards for Reporting Diagnostic Accuracy Studies. Methods We prospectively performed cEEG in nontraumatic, high‐grade SAH patients at a single institution. The index test consisted of clinical neurophysiologists prospectively reporting prespecified EEG alarms: (1) decreasing relative alpha variability, (2) decreasing alpha‐delta ratio, (3) worsening focal slowing, or (4) late appearing epileptiform abnormalities. The diagnostic reference standard was DCI determined by blinded, adjudicated review. Primary outcome measures were sensitivity and specificity of cEEG for subsequent DCI, determined by multistate survival analysis, adjusted for baseline risk. Results One hundred three of 227 consecutive patients were eligible and underwent cEEG monitoring (7.7‐day mean duration). EEG alarms occurred in 96.2% of patients with and 19.6% without subsequent DCI (1.9‐day median latency, interquartile range = 0.9–4.1). Among alarm subtypes, late onset epileptiform abnormalities had the highest predictive value. Prespecified EEG findings predicted DCI among patients with low (91% sensitivity, 83% specificity) and high (95% sensitivity, 77% specificity) baseline risk. Interpretation cEEG accurately predicts DCI following SAH and may help target therapies to patients at highest risk of secondary brain injury. Ann Neurol 2018;83:958–969
ISSN:0364-5134
1531-8249
DOI:10.1002/ana.25232