Muniz Carlos F, Shenoy Apeksha V, OʼConnor Kathryn L, Bechek Sophia C, Boyle Emily J, Guanci Mary M, Tehan Tara M, Zafar Sahar F, Cole Andrew J, Patel Aman B, Westover Michael B, Rosenthal Eric S
*Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; †School of Kinesiology, University of Michigan, Ann Arbor, Michigan, U.S.A.; ‡Stanford University School of Medicine, Stanford, California, U.S.A.; and Departments of §Nursing and ‖Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
J Clin Neurophysiol. 2016 Jun;33(3):217-26. doi: 10.1097/WNP.0000000000000281.
Delayed cerebral ischemia (DCI) is the most common and disabling complication among patients admitted to the hospital for subarachnoid hemorrhage (SAH). Clinical and radiographic methods often fail to detect DCI early enough to avert irreversible injury. We assessed the clinical feasibility of implementing a continuous EEG (cEEG) ischemia monitoring service for early DCI detection as part of an institutional guideline. An institutional neuromonitoring guideline was designed by an interdisciplinary team of neurocritical care, clinical neurophysiology, and neurosurgery physicians and nursing staff and cEEG technologists. The interdisciplinary team focused on (1) selection criteria of high-risk patients, (2) minimization of safety concerns related to prolonged monitoring, (3) technical selection of quantitative and qualitative neurophysiologic parameters based on expert consensus and review of the literature, (4) a structured interpretation and reporting methodology, prompting direct patient evaluation and iterative neurocritical care, and (5) a two-layered quality assurance process including structured clinician interviews assessing events of neurologic worsening and an adjudicated consensus review of neuroimaging and medical records. The resulting guideline's clinical feasibility was then prospectively evaluated. The institutional SAH monitoring guideline used transcranial Doppler ultrasound and cEEG monitoring for vasospasm and ischemia monitoring in patients with either Fisher group 3 or Hunt-Hess grade IV or V SAH. Safety criteria focused on prevention of skin breakdown and agitation. Technical components included monitoring of transcranial Doppler ultrasound velocities and cEEG features, including quantitative alpha:delta ratio and percent alpha variability, qualitative evidence of new focal slowing, late-onset epileptiform activity, or overall worsening of background. Structured cEEG reports were introduced including verbal communication for findings concerning neurologic decline. The guideline was successfully implemented over 27 months, during which neurocritical care physicians referred 71 SAH patients for combined transcranial Doppler ultrasound and cEEG monitoring. The quality assurance process determined a DCI rate of 48% among the monitored population, more than 90% of which occurred during the duration of cEEG monitoring (mean 6.9 days) beginning 2.7 days after symptom onset. An institutional guideline implementing cEEG for SAH ischemia monitoring and reporting is feasible to implement and efficiently identify patients at high baseline risk of DCI during the period of monitoring.
迟发性脑缺血（DCI）是因蛛网膜下腔出血（SAH）入院患者中最常见且致残的并发症。临床和影像学方法常常无法足够早期地检测出DCI以避免不可逆损伤。我们评估了实施持续脑电图（cEEG）缺血监测服务用于早期检测DCI作为机构指南一部分的临床可行性。一项机构神经监测指南由神经重症监护、临床神经生理学、神经外科医生以及护理人员和cEEG技术人员组成的跨学科团队设计。该跨学科团队关注以下方面：（1）高危患者的选择标准；（2）将与长时间监测相关的安全问题最小化；（3）基于专家共识和文献回顾对定量和定性神经生理参数进行技术选择；（4）一种结构化的解读和报告方法，促使对患者进行直接评估和反复的神经重症监护；（5）一个两层质量保证流程，包括评估神经功能恶化事件的结构化临床医生访谈以及对神经影像学和病历的裁定性共识审查。然后对所得指南的临床可行性进行前瞻性评估。该机构的SAH监测指南对Fisher 3级或Hunt-Hess IV级或V级SAH患者使用经颅多普勒超声和cEEG监测进行血管痉挛和缺血监测。安全标准侧重于预防皮肤破损和躁动。技术组成部分包括监测经颅多普勒超声速度和cEEG特征，包括定量的α:δ比值和α波变异性百分比、新出现的局灶性慢波、迟发性癫痫样活动或背景整体恶化的定性证据。引入了结构化的cEEG报告，包括关于神经功能衰退发现的口头交流。该指南在27个月内成功实施，在此期间神经重症监护医生将71例SAH患者转诊进行经颅多普勒超声和cEEG联合监测。质量保证流程确定监测人群中DCI发生率为48%，其中超过90%发生在cEEG监测期间（平均6.9天），始于症状出现后2.7天。一项实施cEEG用于SAH缺血监测和报告的机构指南在监测期间实施并有效识别基线DCI高风险患者是可行的。
