Seizure Detection by Critical Care Providers Using Amplitude-Integrated Electroencephalography and Color Density Spectral Array in Pediatric Cardiac Arrest Patients

Abstract

Objectives: Determine the accuracy and confidence of critical care medicine providers to identify seizures using amplitude-integrated electroencephalography versus amplitude-integrated electroencephalography combined with color density spectral array electroencephalography (aEEG + CDSA).

Design: Tutorial and questionnaire.

Setting: PICU.

Subjects: Pediatric critical care providers (attendings, fellows, and nurses).

Interventions: A standardized powerpoint tutorial on amplitude-integrated electroencephalography and color density spectral array followed by classification of 100 amplitude-integrated electroencephalography images and 100 amplitude-integrated electroencephalography combined with color density spectral array as displaying seizures or not displaying seizures.

Measurements and main results: Electroencephalography tracings were obtained from children monitored with continuous electroencephalography after cardiac arrest. The gold standard for seizure identification was continuous electroencephalography interpretation by a pediatric electroencephalographer. The same electroencephalography tracings were used to generate images containing only amplitude-integrated electroencephalography or aEEG + CDSA. Twenty-three critical care medicine providers underwent a 30-minute tutorial on amplitude-integrated electroencephalography and color density spectral array interpretation. They were then asked to determine if there were seizures on 100 amplitude-integrated electroencephalography images and 100 aEEG + CDSA. Amplitude-integrated electroencephalography seizure detection sensitivity was 77% (95% CI, 73%-80%), specificity of 65% (95% CI, 62%-67%), negative predictive value of 88% (95% CI, 86%-90%), and positive predictive value of 46% (95% CI, 43%-49%). For aEEG + CDSA, sensitivity was 77% (95% CI, 74%-81%), specificity of 68% (95% CI, 66%-71%), negative predictive value of 89% (95% CI, 87%-90%), and positive predictive value of 49% (95% CI, 46%-52%). Sensitivity for status epilepticus detection was 77% (95% CI, 71%-82%) with amplitude-integrated electroencephalography and 75% (95% CI, 69%-81%) with aEEG + CDSA. The addition of color density spectral array to amplitude-integrated electroencephalography did not improve seizure detection. However, 87% of critical care medicine providers qualitatively felt that combining both modalities increased their ability to detect seizures.

Conclusions: Amplitude-integrated electroencephalography and aEEG + CDSA offer reasonable sensitivity and negative predictive value for seizure detection by critical care medicine providers. aEEG + CDSA did not improve seizure detection over amplitude-integrated electroencephalography alone although critical care medicine providers felt more confident using both tools combined. Amplitude-integrated electroencephalography and color density spectral array require further evaluation as a tool for screening for seizures and should only be used in conjunction with professional continuous electroencephalography review.

Fig. 1

(A) Amplitude-integrated EEG (aEEG) and (B) Color Density Spectral Array (CDSA) image (B) for two hours. (A): aEEG: The red tracing represents the right hemisphere, the blue tracing represents the left hemisphere, and the pink tracing represents both hemispheres. The y-axis represents amplitude (0–100uV). The arrows correspond to seizures. Seizures start with a sharp ramp-up in amplitude tracing (upper and lower margins) and are followed by a rapid decline in amplitude tracing. (B): CDSA: The top panel displays the left hemisphere and the lower panel displays the right hemisphere. The y-axis represents frequency (0–20 Hz). Power (amplitude²/Hz) is displayed as color. Red and white represent high power, green is moderate power and blue represents low power. The arrows correspond to seizures. Background is low power (blue) in all frequencies. Seizures start with an increase in power in the low frequency range (green) followed by an increase in power in both high and low frequencies (red and white). After the seizure, the power decreases back to baseline.