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February 4, 2019
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Teaching NeuroImages: Acute stroke captured on EEG in the ICU
Visual and quantitative analysis

February 5, 2019 issue
92 (6) e626-e627
A 56-year-old man underwent a complicated left carotid endarterectomy, ultimately resulting in complete arterial ligation. Postoperative examination was nonfocal; CT perfusion noted vulnerability of the left middle cerebral artery (MCA) territory (figure 1, A–C). EEG placed for ischemia monitoring was initially symmetric (figure 2A). Overnight, new left temporal attenuation was noted, a hallmark of cortical ischemia1 (figure 2B), which prompted clinical evaluation. Quantitative EEG (QEEG) showed simultaneous decreases in left hemispheric 30–64 Hz power and amplitude-integrated EEG, followed by delayed reduction in left alpha/delta ratio (figure 2C). Subsequent examination revealed new right hemiparesis, and MRI showed left MCA infarction (figure 2D). Thus, QEEG can detect cerebral ischemia and provide timely information in the intensive care unit.2
Figure 1 CT perfusion imaging prior to stroke
(A) Increased mean transit time, (B) decreased cerebral blood flow, and (C) unchanged cerebral blood volume in the left middle cerebral artery territory indicate an area at risk for infarct.
Figure 2 Raw and quantitative EEG before/after stroke and MRI after stroke
(A) Baseline EEG before presumed time of stroke. (B) EEG: left hemispheric, temporal maximal attenuation of faster frequencies after stroke (brackets). (C) Spectrogram: acute reduction of higher frequency activity over the left hemisphere (white arrow); quantitative EEG (red tracings correspond to the right hemisphere, blue tracings to the left hemisphere): simultaneous reductions in left hemispheric 30–64 Hz power (black arrow) and amplitude-integrated EEG (purple arrow), with delayed drop in alpha/delta ratio 15 minutes later (bracket) (Insight II software, version 11 [Persyst Development Corporation, Prescott, AZ]). (D) MRI brain, diffusion-weighted imaging sequence, shows completed left middle cerebral artery infarct.

Appendix Authors

Footnote

Teaching slides links.lww.com/WNL/A802

References

1.
Jordan KG. Emergency EEG and continuous EEG monitoring in acute stroke. J Clin Neurophysiol 2004;21:341–352.
2.
Foreman B, Claassen J. Quantitative EEG for the detection of brain ischemia. Crit Care 2012;16:216.

Information & Authors

Information

Published In

Neurology®
Volume 92Number 6February 5, 2019
Pages: e626-e627
PubMed: 30718331

Publication History

Published online: February 4, 2019
Published in print: February 5, 2019

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Disclosure

B. Kamitaki is employed by Rutgers–Robert Wood Johnson University, reads inpatient EEG studies, and bills for these studies; he has no other disclosures. B. Tu is employed by Columbia University Medical Center and reads inpatient EEG studies; he has no other disclosures. A. Reynolds reports no disclosures relevant to the manuscript. C. Schevon has research support from NIH (R01 NS084142 and R01 NS095368) and reads inpatient EEG studies in the course of her employment at Columbia University Medical Center and bills for these studies. Go to Neurology.org/N for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Brad K. Kamitaki, MD
From the Department of Neurology (B.K.K.), Rutgers–Robert Wood Johnson Medical School, Piscataway Township, NJ; Department of Neurology (B.T., C.A.S.), Columbia University Medical Center; and Department of Neurosurgery (A.S.R.), Icahn School of Medicine at Mount Sinai, New York, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Bin Tu, MD, PhD
From the Department of Neurology (B.K.K.), Rutgers–Robert Wood Johnson Medical School, Piscataway Township, NJ; Department of Neurology (B.T., C.A.S.), Columbia University Medical Center; and Department of Neurosurgery (A.S.R.), Icahn School of Medicine at Mount Sinai, New York, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Alexandra S. Reynolds, MD
From the Department of Neurology (B.K.K.), Rutgers–Robert Wood Johnson Medical School, Piscataway Township, NJ; Department of Neurology (B.T., C.A.S.), Columbia University Medical Center; and Department of Neurosurgery (A.S.R.), Icahn School of Medicine at Mount Sinai, New York, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Catherine A. Schevon, MD, PhD
From the Department of Neurology (B.K.K.), Rutgers–Robert Wood Johnson Medical School, Piscataway Township, NJ; Department of Neurology (B.T., C.A.S.), Columbia University Medical Center; and Department of Neurosurgery (A.S.R.), Icahn School of Medicine at Mount Sinai, New York, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Travel compensation (train fare and hotel) by Epilepsy Foundation for role as co-chair of the "My Brain Map" workshop sponsored by the Epilepsy Innovation Institute, Arlington, VA, September 2018.
Editorial Boards:
1.
Editorial advisory board member, Brain (Oxford Journals) - no compensation
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
Columbia University Medical Center faculty practice, clinical responsibilities include inpatient continuous EEG study interpretation, 20% effort/year. No changes in clinical activity anticipated as a direct result of this study.
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NIH NINDS R01-NS084142 and R01 NS-095368
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Citizens United for Research in Epilepsy (CURE) Henry Lapham Memorial Award
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
Provided expert opinion and affidavits for Wilson Elser Moskowitz Edelman & Dicker LLP, White Plains NY, on behalf of academic physician defendants of malpractice lawsuits.

Notes

Correspondence Dr. Kamitaki [email protected]
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

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Cited By
  1. Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children, Neurocritical Care, 38, 3, (791-811), (2023).https://doi.org/10.1007/s12028-023-01690-9
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  2. Quantitative EEG Analysis in Intensive Care Patients, Handbook of Neuroengineering, (3169-3195), (2023).https://doi.org/10.1007/978-981-16-5540-1_91
    Crossref
  3. Quantitative EEG Analysis in Intensive Care Patients, Handbook of Neuroengineering, (1-27), (2022).https://doi.org/10.1007/978-981-15-2848-4_91-1
    Crossref
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