Electroencephalography Monitoring for Seizure Risk Stratification in the Critically III

Seizures and epileptiform abnormalities (EAs) are common in critically ill patients, are frequently clinically silent, and are associated with worse outcomes. Continuous electroencephalography (cEEG) remains an essential tool in the diagnosis and management of electrographic seizures (ESz) and EAs in this population, leading to its increased use in critical settings. However, cEEG is resource-intensive, and prolonged monitoring for all patients may not be feasible or necessary in many practice environments.

The growing demand for cEEG in critically ill patients has created a need for strategies that optimize its use and prioritize monitoring for patients at highest seizure risk. This need has supported the development of seizure forecasting and cEEG duration-guided risk-stratification approaches. The 2HELPS2B score incorporates early EEG and clinical features to estimate seizure risk, guide monitoring duration, and supports more efficient use of cEEG resources. It has been validated and clinically implemented in critical care settings. This review outlines the evolution and importance of cEEG in critical care, beginning with the recognition that many seizures in this population are electrographic, followed by the identification of rhythmic or periodic patterns and their clinical significance, the expanding use of cEEG, the clinical characterization of patients at highest seizure risk, and the development of the 2HELPS2B score to guide efficient cEEG utilization.