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Seizure Frequency and Neurological Decline in Pediatric Intensive Care

Summary and Comment |
April 29, 2014

Seizure Frequency and Neurological Decline in Pediatric Intensive Care

  1. Robert C. Knowlton, MD, MSPH

What is the value of detecting subclinical seizures in the pediatric ICU?

  1. Robert C. Knowlton, MD, MSPH

As in adults, both clinical and subclinical seizures are common in critically ill children, yet the effect of subclinical and nonconvulsive clinical seizures in the context of severe acute illness on outcome remains unknown. To address this question, researchers conducted a relatively large, prospective, observational study of all patients admitted to pediatric and cardiac intensive care units (ICUs) at one institution who underwent continuous video electroencephalography (VEEG) monitoring during a 3-year period (2009–2012). The primary measures were seizure burden (maximum hourly percentile and total), diagnostic category (acute brain injury, acute seizures, or systemic disease), illness severity, change in Pediatric Cerebral Performance Category score between admission and discharge (short-term outcome), and in-hospital mortality. Common and well-accepted clinical indications for continuous VEEG were used as part of standard care.

In all diagnostic categories, after controlling for illness severity, both the probability and magnitude of neurological decline were associated with seizure burden measures. A threshold of 12 minutes per hour of seizure activity was identified, above which an increased degree of neurological decline was likely. Mortality was not associated with seizure burden. The authors conclude that seizures independently contribute to brain injury. They further state the findings suggest that “early and aggressive treatment is warranted” in this population.

Comment

This observational study provides initial support for the hypothesis that the amount of seizure activity in critically ill children treated in ICUs has a harmful effect on neurological outcome. As the authors acknowledge, the study was not designed to answer whether treatment of the seizures makes a difference, so it is surprising that they make such a strong concluding statement about aggressive treatment. Even limiting the scope of the findings to an association of seizure burden with short-term neurological decline does not answer the question of whether the seizures are the cause of harm. The attempt to control for etiology was simplified to only three broad diagnostic categories that might not account for other major contributors to outcome. The possibility remains that persistent seizures (despite optimal detection and treatment as in this study) are merely a symptom flag for an illness destined to have poor short-term outcome. Before we make any recommendations for patient care, these findings should prompt and direct further study to determine whether subtle seizures unable to be detected without continuous VEEG cause irreversible neurological harm.

  • Disclosures for Robert C. Knowlton, MD, MSPH at time of publication Consultant / Advisory board Upsher-Smith Laboratories, Inc.; University of Alabama at Birmingham, Dept. of Neurology Speaker’s bureau Eisai Grant / Research support NIH-NINDS Leadership positions in professional societies Southern Epilepsy & EEG Society (Treasurer)

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