A Bedside Screening Tool for Acute Intracranial Hemorrhages in Intubated Children using Continuous Quantitative Electroencephalography Monitoring

Abstract

Significance Recognition of intracranial hemorrhage is challenging in children who require deep sedation to tolerate mechanical ventilation. The Correlate Of Injury to the Nervous System (COIN) index may enable real-time recognition of intracranial hemorrhage at bedside.

Methods Retrospective analysis of electroencephalography (EEG) data from children with spontaneous intracranial hemorrhage while intubated and sedated in the pediatric intensive care unit. Patients were selected for having normal head imaging at time of EEG start and required demonstration of hemorrhage on repeat imaging following an uninterrupted period of EEG recording. Power spectrum data were analyzed to yield a COIN value and visualization for every 4 seconds of recording. EEG recordings were subdivided based on COIN-risk alarm states (low, medium, or high). Changes in COIN were compared with changes in commercially available quantitative EEG trending software. COIN values for each subdivision were compared within cases using the Wilcoxon Rank-Sum Test.

Results Two children developed spontaneous intracranial hemorrhage while intubated. COIN shows transitions from low-to-medium (p < 0.001) and medium-to-high-risk (p < 0.001 in both cases) alarm states. Discrete transitions in COIN alarm state preceded clinical recognition of hemorrhage by several hours. COIN visualized focal power attenuation concordant with hemorrhage localization. In both cases, qualitative EEG was not reported to have focal abnormalities during the medium-risk alarm state.

Conclusion COIN may assist in real-time recognition of intracranial hemorrhage in children at bedside. Further study and development are required for clinical implementation of COIN in several clinical settings where patients are at high risk of new or worsening intracranial hemorrhage.

Keywords

quantitative EEG - neuromonitoring - intracranial hemorrhage - pediatric neurocritical care

Publikationsverlauf

Eingereicht: 01. Mai 2024

Angenommen: 14. Juni 2024

Artikel online veröffentlicht:
05. Juli 2024

• References

• 1 Loggini A, Del Brutto VJ, El Ammar F. et al. Intracranial hemorrhage in hospitalized patients: an infrequently studied condition with high mortality. Neurocrit Care 2020; 33 (03) 725-731
• 2 Tahir RA, Rotman LE, Davis MC. et al. Intracranial hemorrhage in patients with a left ventricular assist device. World Neurosurg 2018; 113: e714-e721
• 3 Cavayas YA, Del Sorbo L, Fan E. Intracranial hemorrhage in adults on ECMO. Perfusion 2018; 33 (1_suppl): 42-50
• 4 Werho DK, Pasquali SK, Yu S. et al; ELSO Member Centers. Epidemiology of stroke in pediatric cardiac surgical patients supported with extracorporeal membrane oxygenation. Ann Thorac Surg 2015; 100 (05) 1751-1757
• 5 Chen CY, Tai CH, Cheng A. et al. Intracranial hemorrhage in adult patients with hematological malignancies. BMC Med 2012; 10 (01) 97
• 6 Najima Y, Ohashi K, Miyazawa M. et al. Intracranial hemorrhage following allogeneic hematopoietic stem cell transplantation. Am J Hematol 2009; 84 (05) 298-301
• 7 Curley MAQ, Wypij D, Watson RS. et al; RESTORE Study Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators Network. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. JAMA 2015; 313 (04) 379-389
• 8 Cheng HH, Rajagopal S, McDavitt E. et al. Stroke in acquired and congenital heart disease patients and its relationship to hospital mortality and lasting neurologic deficits. Pediatr Crit Care Med 2016; 17 (10) 976-983
• 9 Hanalioglu D, Temkit M, Hildebrandt K. et al. Neurophysiologic features reflecting brain injury during pediatric ECMO support. Neurocrit Care 2024; 40 (02) 759-768
• 10 Benedetti GM, Morgan LA, Sansevere AJ. et al; Pediatric Quantitative EEG Strategic Taskforce (PedQuEST). The Spectrum of quantitative EEG utilization across North America: a cross-sectional survey. Pediatr Neurol 2023; 141: 1-8
• 11 Gavvala J, Abend N, LaRoche S. et al; Critical Care EEG Monitoring Research Consortium (CCEMRC). Continuous EEG monitoring: a survey of neurophysiologists and neurointensivists. Epilepsia 2014; 55 (11) 1864-1871
• 12 Caffarelli M, Karukonda V, Aghaeeaval M. et al; SIPS Investigators. A quantitative EEG index for the recognition of arterial ischemic stroke in children. Clin Neurophysiol 2023; 156: 113-124
• 13 Oostenveld R, Fries P, Maris E, Schoffelen JM. FieldTrip: open source software for advanced analysis of MEG, EEG, and invasive electrophysiological data. Comput Intell Neurosci 2011; 2011: 156869
• 14 McMichael ABV, Ryerson LM, Ratano D, Fan E, Faraoni D, Annich GM. 2021 ELSO adult and pediatric anticoagulation guidelines. ASAIO J 2022; 68 (03) 303-310
• 15 Claassen J, Hirsch LJ, Kreiter KT. et al. Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage. Clin Neurophysiol 2004; 115 (12) 2699-2710
• 16 van Putten MJAM. The revised brain symmetry index. Clin Neurophysiol 2007; 118 (11) 2362-2367
• 17 Sansevere AJ, DiBacco ML, Akhondi-Asl A. et al. EEG features of brain injury during extracorporeal membrane oxygenation in children. Neurology 2020; 95 (10) e1372-e1380
• 18 Abend NS, Arndt DH, Carpenter JL. et al. Electrographic seizures in pediatric ICU patients: cohort study of risk factors and mortality. Neurology 2013; 81 (04) 383-391
• 19 Herman ST, Abend NS, Bleck TP. et al; Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol 2015; 32 (02) 87-95