Guiding Antiepileptic Therapy in a Pediatric Patient with Severe Meningoencephalitis and Decompressive Craniectomy with the Use of Amplitude-Integrated Electroencephalography

Karl F. Schettler; Beatrice Heineking; Silvia Fernandez-Rodriguez; Angelika Pilger; Nikolaus Alexander Haas

doi:10.1055/s-0036-1587328

Journal of Pediatric Intensive Care, Inhaltsverzeichnis

J Pediatr Intensive Care 2017; 06(02): 136-141
DOI: 10.1055/s-0036-1587328

Case Report

Georg Thieme Verlag KG Stuttgart · New York

Guiding Antiepileptic Therapy in a Pediatric Patient with Severe Meningoencephalitis and Decompressive Craniectomy with the Use of Amplitude-Integrated Electroencephalography

Karl F. Schettler

¹Department of Pediatric Cardiology and Pediatric Intensive Care, Campus Grosshadern of the Ludwig Maximilians University, Munich, Germany

,

Beatrice Heineking

¹Department of Pediatric Cardiology and Pediatric Intensive Care, Campus Grosshadern of the Ludwig Maximilians University, Munich, Germany

,

Silvia Fernandez-Rodriguez

¹Department of Pediatric Cardiology and Pediatric Intensive Care, Campus Grosshadern of the Ludwig Maximilians University, Munich, Germany

,

Angelika Pilger

¹Department of Pediatric Cardiology and Pediatric Intensive Care, Campus Grosshadern of the Ludwig Maximilians University, Munich, Germany

,

Nikolaus Alexander Haas

¹Department of Pediatric Cardiology and Pediatric Intensive Care, Campus Grosshadern of the Ludwig Maximilians University, Munich, Germany

› Institutsangaben

Abstract

Introduction Amplitude-integrated electroencephalography (aEEG) is one of the most widely used neuromonitoring tools in neonatology today. However, little is known about its clinical indications and potential benefits in pediatric intensive care patients. Based on limited experience, its impact on therapeutic decision-making in this patient population is unclear.

Case Description We report the case of a 16-year-old boy who, after a pansinusitis, developed a severe meningoencephalitis and intracranial empyema with increased intracranial pressure that required drainage and decompressive craniectomy. He subsequently developed status epilepticus despite a combination of various anticonvulsants. Only after the initialization of an aEEG, we were able to adequately diagnose and continuously monitor his seizure activity and titrate the effect of the antiepileptic drugs. During his hospital stay, we were able to clearly monitor and guide our therapy by accurately identifying the termination of status epilepticus and the recurrence of seizures.

Discussion With the help of aEEG, it was easy to identify the nonconvulsive status epilepticus (NCSE) and the ongoing seizure activity in this teenage patient. NCSE is a clinical problem with an effect on the outcome of the patient and is often underdiagnosed. AEEG enabled a rapid detection and management of seizure activity and thereby reduced the overall seizure burden, which was associated with better neurologic outcome.

Keywords

amplitude-integrated EEG - antiepileptic therapy - meningoencephalitis - neuromonitoring - nonconvulsive status epilepticus

Volltext

Referenzen

References
1 Maynard D, Prior PF, Scott DF. Device for continuous monitoring of cerebral activity in resuscitated patients. BMJ 1969; 4 (5682): 545-546
2 Toet MC, Lemmers PMA. Brain monitoring in neonates. Early Hum Dev 2009; 85 (2) 77-84
3 Yin X-J, Wei W, Han T , et al. Value of amplitude-integrated electroencephalograph in early diagnosis and prognosis prediction of neonatal hypoxic-ischemic encephalopathy. Int J Clin Exp Med 2014; 7 (4) 1099-1104
4 Zhang D, Ding H, Liu L , et al. The prognostic value of amplitude-integrated eeg in full-term neonates with seizures. PLoS ONE 2013; 8 (11) e78960 . Doi: 10.1371/journal.pone.0078960
5 Sohn JA, Kim HS, Lee EH , et al. Developmental change of amplitude-integrated electroencephalographic activity in preterm infants with intraventricular hemorrhage. Early Hum Dev 2013; 89 (12) 961-966
6 Olischar M, Klebermass K, Kuhle S, Hulek M, Messerschmidt A, Weninger M. Progressive posthemorrhagic hydrocephalus leads to changes of amplitude-integrated EEG activity in preterm infants. Childs Nerv Syst 2004; 20 (1) 41-45
7 Olischar M, Shany E, Aygün C , et al. Amplitude-integrated electroencephalography in newborns with inborn errors of metabolism. Neonatology 2012; 102 (3) 203-211
8 Song J, Xu F, Wang L , et al. Early amplitude-integrated electroencephalography predicts brain injury and neurological outcome in very preterm infants. Sci Rep 2015; 5: 13810 . Doi: 10.1038/srep13810
9 Igarashi A, Okumura A, Komatsu M , et al. Amplitude-integrated EEG revealed nonconvulsive status epilepticus in children with non-accidental head injury. Eur J Paediatr Neurol 2014; 18 (6) 806-810
10 Mittnacht AJ, Rodriguez-Diaz C. Multimodal neuromonitoring in pediatric cardiac anesthesia. Ann Card Anaesth 2014; 17 (1) 25-32
11 Galgano MA, Tovar-Spinoza Z. Multimodality neuromonitoring in pediatric neurocritical care: review of the current resources. Cureus 2015; 7 (11) e385 . Doi: 10.7759/cureus.385
12 Glass HC, Wusthoff CJ, Shellhaas RA. Amplitude integrated EEG: the child neurologist's perspective. J Child Neurol 2013; 28 (10) 1342-1350
13 Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M ; Neurointensive Care Section of the European Society of Intensive Care Medicine. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39 (8) 1337-1351
14 Walker M, Cross H, Smith S , et al. Nonconvulsive status epilepticus: Epilepsy Research Foundation workshop reports. Epileptic Disord 2005; 7 (3) 253-296
15 Korff CM, Nordli Jr DR. Diagnosis and management of nonconvulsive status epilepticus in children. Nat Clin Pract Neurol 2007; 3 (9) 505-516
16 Mallick AA, Ganesan V, Kirkham FJ , et al. Outcome and recurrence one year after paediatric arterial ischaemic stroke in a population-based cohort. Ann Neurol 2016;
17 Lingappa L, Konanki R, Patel R, Vooturi S, Jayalakshmi S. Clinical profile and outcome of refractory convulsive status epilepticus in older children from a developing country. Seizure 2016; 36: 31-35
18 Kim YS, Jung KH, Lee ST , et al. Prognostic value of initial standard EEG and MRI in patients with herpes simplex encephalitis. J Clin Neurol 2016; 12 (2) 224-229
19 Singh A, Lomash A, Pandey S, Kapoor S. Clinical, biochemical and outcome profile of biotinidase deficient patients from tertiary centre in Northern India. J Clin Diagn Res 2015; 9 (12) SC08-SC10
20 Pardo AC. Impact of seizure burden in hypoxic ischemic encephalopathy. Pediatr Neurol Briefs 2015; 29 (10) 74 . Doi: 10.15844/pedneurbriefs-29-10-1
21 Hocker SE, Britton JW, Mandrekar JN, Wijdicks EF, Rabinstein AA. Predictors of outcome in refractory status epilepticus. JAMA Neurol 2013; 70 (1) 72-77
22 Claassen J, Hirsch LJ, Emerson RG, Bates JE, Thompson TB, Mayer SA. Continuous EEG monitoring and midazolam infusion for refractory nonconvulsive status epilepticus. Neurology 2001; 57 (6) 1036-1042
23 Hyllienmark L, Amark P. Continuous EEG monitoring in a paediatric intensive care unit. Eur J Paediatr Neurol 2007; 11 (2) 70-75
24 Friberg H, Westhall E, Rosén I, Rundgren M, Nielsen N, Cronberg T. Clinical review: continuous and simplified electroencephalography to monitor brain recovery after cardiac arrest. Crit Care 2013; 17 (4) 233 . Doi: 10.1186/cc12699
25 Dericioglu N, Yetim E, Bas DF , et al. Non-expert use of quantitative EEG displays for seizure identification in the adult neuro-intensive care unit. Epilepsy Res 2015; 109: 48-56
26 Karakis I, Montouris GD, Otis JA , et al. A quick and reliable EEG montage for the detection of seizures in the critical care setting. J Clin Neurophysiol 2010; 27 (2) 100-105
27 Young GB, Sharpe MD, Savard M, Al Thenayan E, Norton L, Davies-Schinkel C. Seizure detection with a commercially available bedside EEG monitor and the subhairline montage. Neurocrit Care 2009; 11 (3) 411-416