A Commentary on Electrographic Seizure Management and Clinical Outcomes in Critically Ill Children
Lily Tran1, Rebecca Welcher1, Rodney Scott1
1Nemours Children's Health System Division of Neurology, 1600 Rockland Rd., Wilmington, DE 19803, USA.
Insights
Continuous EEG monitoring detects seizures in critically ill children. Emerging evidence suggests treatment may not improve outcomes unless seizure burden is high, advocating for a tailored approach.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Clinical Neurophysiology
Background:
- Continuous electroencephalogram (cEEG) monitoring is standard for detecting electrographic seizures in critically ill children.
- Current guidelines recommend urgent cEEG, but evidence for improved outcomes with antiseizure medication is limited.
- This raises questions about the necessity of aggressive seizure treatment strategies.
Purpose of the Study:
- To re-evaluate current consensus guidelines for treating electrographic seizures in critically ill children.
- To explore the association between seizure burden and neurological outcomes.
- To propose a tailored therapeutic approach based on seizure burden thresholds.
Main Methods:
- Review of existing evidence on cEEG monitoring and antiseizure medication efficacy.
- Analysis of the relationship between electrographic seizures, seizure burden, and neurological outcomes.
- Formulation of recommendations for future clinical practice and research.
Main Results:
- Electrographic seizures alone may not be linked to poor neurological outcomes in critically ill children.
- High seizure burden and electrographic status epilepticus are associated with adverse outcomes, warranting treatment.
- Neurological outcomes are more strongly influenced by the underlying etiology than by seizures themselves.
Conclusions:
- Current aggressive treatment strategies to abolish all electrographic seizures may need re-evaluation.
- A tailored approach, intervening when seizure burden exceeds critical thresholds, is recommended.
- Future research should validate the impact of treating electrographic seizures and status epilepticus on outcomes.
Abstract:
Continuous EEG (cEEG) monitoring is the gold standard for detecting electrographic seizures in critically ill children and the current consensus-based guidelines recommend urgent cEEG to detect electrographic seizures that would otherwise be undetected. The detection of seizures usually leads to the use of antiseizure medications, even though current evidence that treatment leads to important improvements in outcomes is limited, raising the question of whether the current strategies need re-evaluation. There is emerging evidence indicating that the presence of electrographic seizures is not associated with unfavorable neurological outcome, and thus treatment is unlikely to alter the outcomes in these children. However, a high seizure burden and electrographic status epilepticus is associated with unfavorable outcome and the treatment of status epilepticus is currently warranted. Ultimately, outcomes are more likely a function of etiology than of a direct effect of the seizures themselves. We suggest re-examining our current consensus toward aggressive treatment to abolish all electrographic seizures and recommend a tailored approach where therapeutic interventions are indicated when seizure burden breaches above a critical threshold that may be associated with adverse outcomes. Future studies should explicitly evaluate whether there is a positive impact of treating electrographic seizures or electrographic status epilepticus in order to justify continuing current approaches.
