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EEG Patterns and Outcomes After Hypoxic Brain Injury: A Systematic Review and Meta-analysis

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Abstract

Electroencephalography (EEG) is used to prognosticate recovery in comatose patients with hypoxic ischemic brain injury (HIBI) secondary to cardiac arrest. We sought to determine the prognostic use of specific EEG patterns for predicting disability and death following HIBI secondary to cardiac arrest. This systematic review searched Medline, Embase, and Cochrane Central up to January 2020. We included original research involving prospective and retrospective cohort studies relating specific EEG patterns to disability and death in comatose adult patients suffering HIBI post cardiac arrest requiring admission to an intensive care setting. We evaluated study quality using the Quality of Diagnostic Accuracy Studies 2 tool. Descriptive statistics were used to summarize study, patient, and EEG characteristics. We pooled study-level estimates of sensitivity and specificity for EEG patterns defined a priori using a random effect bivariate and univariate meta-analysis when appropriate. Funnel plots were used to assess publication bias. Of 5191 abstracts, 333 were reviewed in full text, of which 57 were included in the systematic review and 32 in meta-analyses. No reported EEG pattern was found to be invariably associated with death or disability across all studies. Pooled specificities of status epilepticus, burst suppression, and electrocerebral silence were high (92–99%), but sensitivities were low (6–39%) when predicting a composite outcome of disability and death. Study quality varied depending on domain; patient flow and timing performed was well conducted in all, whereas EEG interpretation was retrospective in 17 of 39 studies. Accounting for variable study quality, EEG demonstrates high specificity with a low risk of false negative outcome attribution for disability and death when status epilepticus, burst suppression, or electrocerebral silence is detected. Increased use of standardized cross-study protocols and definitions of EEG patterns are required to better evaluate the prognostic use of EEG for comatose patients with HIBI following cardiac arrest.

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Acknowledgements

NJ is the Icahn School of Medicine at Mount Sinai Bludhorn Professor of International Medicine. The authors thank Edilberto Amorim, MD (Department of Neurology, Massachusetts General Hospital, Boston, MA, USA), Jeannette Hofmeijer, MD, and her research group (Department of Neurology, Rijnsate Hospital, Wagnerlaan, Arnhem, The Netherlands), and Hitoshi Kobata, MD (Neurosurgery, Osaka Mishima Emergency Critical Care Center, Osaka, Japan), for their correspondence and willingness to share/clarify their data.

Funding

This study received no funding.

Author information

Authors and Affiliations

  1. Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Kevin Perera, Sundus Khan, Shaily Singh, Julie Kromm, Meng Wang, Tolulope Sajobi, Nathalie Jetté, Samuel Wiebe & Colin B. Josephson

  2. Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Julie Kromm

  3. Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada

    Julie Kromm, Meng Wang, Tolulope Sajobi, Nathalie Jetté, Samuel Wiebe & Colin B. Josephson

  4. Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Meng Wang, Tolulope Sajobi, Nathalie Jetté, Samuel Wiebe & Colin B. Josephson

  5. Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Nathalie Jetté

  6. O’Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada

    Nathalie Jetté, Samuel Wiebe & Colin B. Josephson

  7. Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

    Samuel Wiebe

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  1. Kevin Perera
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  2. Sundus Khan
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  3. Shaily Singh
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  4. Julie Kromm
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  7. Nathalie Jetté
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  8. Samuel Wiebe
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  9. Colin B. Josephson
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Contributions

KP and CJ came up with the study concept. All authors contributed to the study design. KP, SK, MW, and CJ collected and analyzed the data. KP and CB wrote the first draft of the article and all authors commented on previous versions of the article. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kevin Perera.

Ethics declarations

Conflicts of interest

Dr. Tolulope Sajobi is supported by the MSI Foundation New Investigator Grant. Dr. Nathalie Jette receives grant funding paid to her institution for grants unrelated to this work from NINDS (NIH U24NS107201, NIH IU54NS100064). She receives a stipend as an Associate Editor of Epilepsia. Dr. Samuel Wiebe held the Hopewell Professorship of Clinical Neurosciences Research at the University of Calgary. Dr. Colin Josephson has received unrestricted educational grants unrelated to this work from UCB Canada Inc. and Eisai Inc. The remaining authors reports no disclosures or conflicts of interests.

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Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 15 KB)

Supplementary file2 (DOCX 23 KB)

Supplementary file3 (DOCX 17 KB)

Study-level characteristics of all included studies in systematic review. (DOCX 75 KB)

Study-level characteristics of EEGs patterns and its association with death. (DOCX 28 KB)

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Stratified forest plot of the sensitivity and specificity of burst suppression predicting composite outcomes 24 hours before cardiac arrest. (PDF 81 KB)

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Stratified forest plot of the sensitivity and specificity of burst suppression predicting composite outcomes 24 hours after cardiac arrest. (PDF 47 KB)

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Hierarchical summary receiver operating curve for burst suppression predicting death in patients with hypoxic ischemic brain injury following cardiac arrest. (PNG 6 KB)

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Stratified forest plot of the sensitivity and specificity of burst suppression predicting death in patients with hypoxic ischemic brain injury following cardiac arrest. (PDF 55 KB)

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Hierarchical summary receiver operating curve for electrocerebral silence predicting composite outcomes of disability and death in patients with hypoxic ischemic brain injury following cardiac arrest. (PDF 13 KB)

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Stratified forest plot of the sensitivity and specificity of electrocerebral silence predicting composite outcomes in patients with hypoxic ischemic brain injury within the first 24 hours of cardiac arrest. (PDF 18 KB)

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Hierarchical summary receiver operating curve for electrocerebral silence predicting death alone in patients with hypoxic ischemic brain injury following cardiac arrest. (PDF 67 KB)

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Stratified forest plot of the sensitivity and specificity of electrocerebral silence predicting death in patients with hypoxic ischemic brain injury following of cardiac arrest. (PDF 59 KB)

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Hierarchical summary receiver operating curve for status epilepticus in predicting a composite outcome of disability and death in patients with hypoxic ischemic brain injury within the first 24 hours cardiac arrest. (PDF 70 KB)

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Stratified forest plot of the sensitivity and specificity of status epilepticus predicting composite outcomes in patients with hypoxic ischemic brain injury following of cardiac arrest. (PDF 74 KB)

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Hierarchical summary receiver operating curve for status epilepticus in predicting death in patients with hypoxic ischemic brain injury within the first 24 hours cardiac arrest. (PDF 5 KB)

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Stratified forest plot of the sensitivity and specificity of status epilepticus predicting death in patients with hypoxic ischemic brain injury following of cardiac arrest. (PDF 51 KB)

12028_2021_1322_MOESM18_ESM.pdf

Hierarchical summary receiver operating curve for generalized periodic discharges in predicting composite of death and disability in patients with hypoxic ischemic brain injury. (PDF 71 KB)

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Stratified forest plot of the sensitivity and specificity of generalized periodic discharges predicting composite outcome of death and disability in patients with hypoxic ischemic brain injury following of cardiac arrest. (PDF 88 KB)

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Perera, K., Khan, S., Singh, S. et al. EEG Patterns and Outcomes After Hypoxic Brain Injury: A Systematic Review and Meta-analysis. Neurocrit Care 36, 292–301 (2022). https://doi.org/10.1007/s12028-021-01322-0

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