Electroencephalography for prognostication of outcome in adults with severe herpes simplex encephalitis

Electroencephalography (EEG) is recommended for the practical approach to the diagnosis and prognosis of encephalitis. We aimed to investigate the prognostic value of standard EEG (_stdEEG) in adult patients with severe herpes simplex encephalitis.

We performed a retrospective analysis of consecutive ICU patients with severe herpes simplex encephalitis in 38 French centers between 2006 and 2016. Patients with at least one _stdEEG study performed at ICU admission were included. _stdEEG findings were reviewed independently by two investigators. The association between _stdEEG findings (i.e., background activity, lateralized periodic discharges, seizures/status epilepticus, and reactivity to painful/auditory stimuli) and poor functional outcome, defined by a score on the modified Rankin Scale (mRS) of 3 to 6 (moderate to severe disability or death) at 90 days, were investigated.

We included 214 patients with at least one available _stdEEG study. The first _stdEEG was performed after a median time of one (interquartile range (IQR) 0 to 2) day from ICU admission. At the time of recording, 138 (64.5%) patients were under invasive mechanical ventilation. Lateralized periodic discharges were recorded in 91 (42.5%) patients, seizures in 21 (9.8%) and status epilepticus in 16 (7.5%). In the whole population, reactivity to auditory/noxious stimuli was tested in 140/214 (65.4%) patients and was absent in 71/140 (33.2%) cases. In mechanically ventilated patients, _stdEEG reactivity was tested in 91/138 (65.9%) subjects, and was absent in 53/91 (58.2%) cases. Absence of reactivity was the only independent _stdEEG finding associated with poor functional outcome in the whole population (OR 2.80, 95% CI 1.19 to 6.58) and in the subgroup of mechanically ventilated patients (OR 4.99, 95% CI 1.6 to 15.59). Adjusted analyses for common clinical predictors of outcome and sedation at time of _stdEEG revealed similar findings in the whole population (OR 2.03, 95% CI 1.18 to 3.49) and in mechanically ventilated patients (OR 2.62, 95% CI 1.25 to 5.50).

Absence of EEG reactivity to auditory/noxious stimuli is an independent marker of poor functional outcome in severe herpes simplex encephalitis.