Following aEEG introduction, the total number of conventional EEGs performed remained constant; however, there was significant shift in conventional EEG utilization towards neonates receiving fewer multiple EEGs and more single EEGs. There was no change in the rate of neurology consultations or the number of neonates diagnosed with seizures. Conventional electroencephalography remains the gold standard for the diagnosis and quantification of neonatal seizures. However, amplitude-integrated electroencephalography (aEEG) is being introduced to neonatal intensive care as an adjunct for neonatal seizure detection.

Diagnostic value of amplitude-integrated electroencephalogram in neonatal seizures.

Zhang et al reported that investigate the accuracy of amplitude-integrated electroencephalography (aEEG) in detecting full-term neonatal seizures. Conventional EEG (cEEG) and aEEG were simultaneously applied to 62 full-term newborns with seizures and results were analyzed with different methods. 876 seizures confirmed by cEEG, 21% were detected by clinical observation, 44.4% by aEEG and 85.7% by aEEG plus C3/C4 raw EEG. Of 531 seizures with a frequency higher than 5 times/h, 52.5% were detected by aEEG and 96.8% by aEEG plus C3/C4 raw EEG. Of 510 seizures lasting longer than 60 s, 50.6% were diagnosed by aEEG and 84.1% by aEEG plus C3/C4 raw EEG. Of 509 seizures originating in the central region, 57.9% were detected by aEEG and 90.9% by aEEG plus C3/C4 raw EEG. Combination of aEEG with cEEG offers more accurate diagnosis, especially for detecting high-frequency, long-lasting and central region-generated seizures.

Introduction of aEEG monitors to NICU has led to less reliance on conventional EEG as a tool for the serial evaluation of brain function. Since the number of neonates diagnosed with seizures did not increase, aEEG monitoring did not appear to uncover a significant subgroup of patients with subclinical seizures that would previously have gone undetected. Conventional EEG and aEEG are complementary tools for the assessment of newborn cerebral function.

Amplitude-integrated electroencephalography (aEEG) was recently introduced into neonatal intensive care in the United States. Shellhaas RA, et al.reported that evaluated whether aEEG has changed clinical care for neonates with seizures. This study included all 202 neonates treated for seizures at our hospital from 2002-2007. Neonates monitored with aEEG (n = 67) were compared with contemporary control neonates who were not monitored, despite the availability of aEEG (n = 57), and a historic control group of neonates treated for seizures before our neonatal intensive care unit initiated aEEG (n = 78). Eighty-two percent of those receiving phenobarbital (137/167) continued treatment after discharge, with no difference among groups. Adjusted for gestational age and length of stay, no difference among groups was evident in number of neuroimaging studies or number of antiepileptic drugs per patient. Fewer patients undergoing aEEG, compared with contemporary (16/67 vs 29/57, respectively, P = 0.001) or historic (n = 38/78, P = 0.002) controls, were diagnosed clinically with seizures without electrographic confirmation.

The aEEG did not increase neuroimaging tests, and did not alter antiepileptic drug use. However, diagnostic precision regarding neonatal seizures improved with aEEG because fewer neonates were treated for seizures based solely on clinical findings, without electrographic confirmation.

Shellhaas RA, et al.Sensitivity of amplitude-integrated electroencephalography for neonatal seizure detection. Shellhaas RA, et al. Pediatrics. 2007 Oct;120(4):770-7.

Utility of prolonged bedside amplitude-integrated encephalogram in encephalopathic infants

Prolonged bedside limited-channel amplitude-integrated electroencephalogram (aEEG) monitoring following a standard 1-hour conventional electroencephalogram (cEEG) would increase the detection of subclinical seizures and allow continuous evaluation of the background EEG in neonatal encephalopathy. This may identify complementary roles for these EEG technologies in neonatal units where continuous cEEG monitoring may not be readily available.

Mathur et al reported that prospectively recruited 25 term neonates with a diagnosis of neonatal seizures or encephalopathy. All infants underwent a standard 1-hour cEEG followed by 12 to 24 hours of aEEG monitoring. Data from the aEEG (plus the raw signal) were analyzed by an epileptologist and compared with information obtained from the clinical report of the cEEG. aEEG and cEEG data were available for 24 infants. Results from magnetic resonance imaging (MRI) performed at 7 to 10 days of life were available in 23/24 infants.

Background classification on cEEG and aEEG was similar in 83% of patients. Five of 24 infants had normal background on cEEG. Prolonged aEEG detected evolution of background from initially normal to moderately abnormal in an additional four infants. It also detected more subclinical seizures than the 1-hour cEEG in 8/14 infants. Normal background on aEEG and cEEG was associated with normal MRI results, and severe background abnormality (5/24) on both aEEG and cEEG was associated with abnormal MRI results. Data obtained from prolonged aEEG (plus raw EEG) provide similar background activity, enhance seizure detection, and complement standard cEEG in predicting short-term outcomes, based on MRI, in term neonates with seizures or encephalopathy. Limited-channel aEEG technology may provide a pragmatic alternative for longitudinal monitoring of newborn infants with encephalopathy in neonatal units where prolonged video EEG monitoring is not feasible.

Continuous limited-channel aEEG in term infants with encephalopathy

Lawrence et al reported that evaluate the accuracy, feasibility, and impact of limited-channel amplitude integrated electroencephalogram (aEEG) monitoring in encephalopathic infants. Encephalopathic infants were placed on limited-channel aEEG with a software-based seizure event detector for 72 hours. A 12-hour epoch of conventional EEG-video (cEEG) was simultaneously collected. Infants were randomly assigned to monitoring that was blinded or visible to the clinical team. If a seizure detection event occurred in the visible group, the clinical team interpreted whether the event was a seizure, based on review of the limited-channel aEEG. EEG data were reviewed independently offline.

In more than 68 hours per infant of limited-channel aEEG monitoring, 1116 seizures occurred (>90% clinically silent), with 615 detected by the seizure event detector (55%). Detection improved with increasing duration of seizures (73% >30 seconds, 87% >60 seconds). Bedside physicians were able to accurately use this algorithm to differentiate true seizures from false-positives. The visible group had a 52% reduction in seizure burden compared with the blinded group. Monitoring for seizures with limited-channel aEEG can be accurately interpreted, compares favorably with cEEG, and is associated with a trend toward reduced seizure burden.

References:

Appendino JP, et al. The Impact of Amplitude-Integrated Electroencephalography on NICU Practice. Can J Neurol Sci. 2012 May;39(3):355-60.

Shellhaas RA, et al.Impact of amplitude-integrated electroencephalograms on clinical care for neonates with seizures. Pediatr Neurol. 2012 Jan;46(1):32-5.

Mathur AM, et al. Utility of prolonged bedside amplitude-integrated encephalogram in encephalopathic infants. Am J Perinatol. 2008 Nov;25(10):611-5.

Lawrence R, et al. A pilot study of continuous limited-channel aEEG in term infants with encephalopathy.J Pediatr. 2009 Jun;154(6):835-41.e1.

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