Sivaraju Adithya, Gilmore Emily J
Division of Clinical Neurophysiology and Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
Curr Treat Options Neurol. 2016 Feb;18(2):8. doi: 10.1007/s11940-015-0391-0.
Continuous electroencephalographic (EEG) monitoring has become an invaluable tool for the assessment of brain function in critically ill patients. However, interpretation of EEG waveforms, especially in the intensive care unit (ICU) setting is fraught with ambiguity. The term ictal-interictal continuum encompasses EEG patterns that are potentially harmful and can cause neuronal injury. There are no clear guidelines on how to treat EEG patterns that lie on this continuum. We advocate the following approaches in a step wise manner: (1) identify and exclude clear electrographic seizures and status epilepticus (SE), i.e., generalized spike-wave discharges at 3/s or faster; and clearly evolving discharges of any type (rhythmic, periodic, fast activity), whether focal or generalized; (2) exclude clear interictal patterns, i.e., spike-wave discharges, periodic discharges, and rhythmic patterns at 1/s or slower with no evolution, unless accompanied by a clear clinical correlate, which would make them ictal regardless of the frequency; (3) consider any EEG patterns that lie in between the above two categories as being on the ictal-interictal continuum; (4) compare the electrographic pattern of the ictal-incterictal continuum to the normal background and unequivocal seizures (if present) from the same patient; (5) when available, correlate ictal-interictal continuum pattern with other markers of neuronal injury such as neuronal specific enolase (NSE) levels, brain imaging findings, depth electrode recordings, data from microdialysis, intracranial pressure fluctuations, and brain oxygen measurement; and (6) perform a diagnostic trial with preferably a nonsedating antiepileptic drug with the endpoint being both clinical and electrographic improvement. Minimize the use of anesthetics or multiple AEDs unless there is clear supporting evidence from ancillary tests or worsening of the EEG patterns over time, which could indicate possible neuronal injury.
连续脑电图（EEG）监测已成为评估危重症患者脑功能的一项重要工具。然而，EEG波形的解读，尤其是在重症监护病房（ICU）环境中充满了不确定性。发作期 - 发作间期连续体这一术语涵盖了可能有害并可导致神经元损伤的EEG模式。对于如何处理处于这种连续体上的EEG模式，目前尚无明确的指导原则。我们建议采取以下逐步方法：（1）识别并排除明确的脑电图癫痫发作和癫痫持续状态（SE），即每秒3次或更快的全身性棘波 - 慢波放电；以及任何类型（节律性、周期性、快速活动）的明确演变性放电，无论是局灶性还是全身性；（2）排除明确的发作间期模式，即每秒1次或更慢且无演变的棘波 - 慢波放电、周期性放电和节律性模式，除非伴有明确的临床关联，否则无论频率如何，这些模式均视为发作期；（3）将介于上述两类之间的任何EEG模式视为处于发作期 - 发作间期连续体上；（4）将发作期 - 发作间期连续体的脑电图模式与同一患者的正常背景和明确的癫痫发作（如果存在）进行比较；（5）如有可能，将发作期 - 发作间期连续体模式与神经元损伤的其他标志物相关联，如神经元特异性烯醇化酶（NSE）水平、脑成像结果、深部电极记录、微透析数据、颅内压波动和脑氧测量；（6）进行诊断性试验，最好使用非镇静性抗癫痫药物，终点为临床和脑电图改善。除非有辅助检查的明确支持证据或EEG模式随时间恶化（这可能表明可能的神经元损伤），否则应尽量减少麻醉剂或多种抗癫痫药物的使用。
