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Original Investigation |

Brief Potentially Ictal Rhythmic Discharges in Critically Ill Adults

Ji Yeoun Yoo, MD1; Nishi Rampal, MD1; Ognen A. Petroff, MD1; Lawrence J. Hirsch, MD1; Nicolas Gaspard, MD, PhD1
[+] Author Affiliations
1Comprehensive Epilepsy Center and Division of Clinical Neurophysiology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
JAMA Neurol. 2014;71(4):454-462. doi:10.1001/jamaneurol.2013.6238.
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Importance  Brief potentially ictal rhythmic discharges, termed B(I)RDs, have been described mainly in neonates, and their significance in adults remains unclear.

Objective  To describe the incidence of B(I)RDs in critically ill patients and investigate their association with seizures and outcome.

Design, Setting, and Participants  We reviewed the records of prospectively identified patients with B(I)RDs and patients serving as controls matched for age (±5 years) and primary diagnosis.

Main Outcomes and Measures  The prevalence of seizures during continuous electroencephalography and functional outcome, as measured by the Glasgow Outcome Scale, were determined.

Results  We identified B(I)RDs in 20 patients (2%). The pattern most often consisted of very brief (1-3 seconds) runs of sharply contoured theta activity without obvious evolution. All patients with B(I)RDs had cerebral injury, and in cases with a single focal lesion (11 [55%]), B(I)RDs were localized in the same region in all but 2 cases (18%). Patients with B(I)RDs were more likely to have seizures during continuous electroencephalography than were patients without B(I)RDs (15 of 20 [75%] vs 10 of 40 [25%]; P < .001), and 9 patients with B(I)RDs (60%) had only subclinical seizures. Brief potentially ictal rhythmic discharges were identified before seizures in all but 1 case (93%) and ceased in all 12 cases (80%) in which seizures were controlled. Patients with B(I)RDs tended to have a worse outcome than controls (16 [80%] vs 25 [63%]); however, this finding was not statistically significant.

Conclusions and Relevance  Brief potentially ictal rhythmic discharges in critically ill patients are associated with a high prevalence (75%) of electrographic seizures and might serve as an early predictor of seizures during subsequent monitoring. A larger prospective study is needed to better understand their clinical and prognostic significance.

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Figure 1.
Electroencephalogram Recordings of a Woman in Her Late 80s With a Left Temporal Stroke

The patient presented with a new-onset, generalized tonic-clonic seizure and failure to regain full consciousness postictally. A, A 10-second electroencephalogram (EEG) page showing a very brief run of sharply contoured, intermittent rhythmic theta activity (brief potentially ictal rhythmic discharge) over the left anterior region (boxed areas). B and C, Two 10-second EEG pages showing the onset of an electrographic seizure from the left anterior region (boxed areas). High- and low-pass filters were set at 1 and 70 Hz, respectively. The notch filter was off.

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Figure 2.
Electroencephalogram Recordings of a Woman in Her Mid-70s With Anoxic Brain Injury After Cardiac Arrest

The injury resulted from a cardiac arrest. A, A 10-second electroencephalogram (EEG) page showing 2 very brief runs of sinusoidal rhythmic beta activity (brief potentially ictal rhythmic discharges ) over the right anterior region (boxed areas). B and C, Two 10-second EEG pages showing the onset of an electrographic seizure starting from the right anterior region and spreading to the right hemisphere (boxed areas). High- and low-pass filters were set at 1 and 70 Hz, respectively. The notch filter was off.

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Figure 3.
Electroencephalogram Recordings of 2 Patients With Cancer-Associated Seizure Activity

A, A man in his mid-70s with papillary thyroid cancer and brain metastases presented with a new-onset seizure. A 10-second electroencephalogram (EEG) page showing a very brief run of sharply contoured, intermittent rhythmic theta activity (brief potentially ictal rhythmic discharges [B(I)RDs]) was noted over the right anterior temporal region (boxed areas). There was simultaneous occurrence of low-amplitude lateralized periodic discharges (LPDs) (underlined) over the right temporal region. B and C, A man in his late 40s with glioblastoma multiforme and focal motor seizures. B, A 10-second EEG page showing the occurrence of a very brief run of sharply contoured theta activity (B(I)RDs) over the left midtemporal region (boxed area) and independent LPDs with fast activity (underlined) over the left posterior quadrant intermittent. C, Similar runs of theta activity were observed in the absence of LPDs (boxed area). High- and low-pass filters were set at 1 and 70 Hz, respectively. The notch filter was off.

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