Electrographic seizures detected by continuous electroencephalography (CEEG) in critically ill patients with altered mental status are becoming increasingly recognized. Data guiding the appropriate selection of patients to be monitored on CEEG are lacking. The aims of this article were to study the incidence of seizures in the critical care setting and to evaluate for clinical predictors to improve the efficiency of CEEG monitoring. Retrospective review of the CEEG and clinical data on 1,123 consecutive patients who had continuous video EEG over a 24-month period.

Seizures were recorded in 215 patients on CEEG monitoring (19.1%). In total, 89.3% of these seizures occurred without clinical signs. Patients who were in a coma were more likely to have EEG seizures (odds ratio, 3.64; 95% confidence interval, 2.23–5.95) compared with those awake. The incidence of seizures was overrepresented in patients with extra-axial tumors (41.9%), multiple sclerosis (35.7%), and intra-axial tumors (33.0%). Lateralized periodic discharges were predictive (odds ratio, 8.27; 95% confidence interval, 5.52–12.46) of seizure occurrence compared with those with no epileptiform patterns. Only generalized periodic discharges with triphasic morphology had no increased odds of seizure (odds ratio, 1.02; 95% confidence interval, 0.24–3.03). When present, electroencephalography seizures were detected within 24 hours in 92% of monitored patients.

Continuous electroencephalography monitoring in the critical care setting demonstrates a linear increase in seizure incidence with declining mental status. Recognizing clinical conditions and electroencephalography markings may help in the appropriate selection of critically ill patients for CEEG monitoring.

A total of 201 consecutive patients admitted to the MICU between July 2004 and January 2007 without known acute neurologic injury and who underwent continuous electroencephalography monitoring (cEEG) for investigation of possible seizures or changes in mental status. Patients with sepsis had a higher rate of ESZs or PEDs than those without sepsis (32% vs. 9%, p < 0.001). On multivariable analysis, sepsis at ICU admission was the only significant predictor of ESZs or PEDs (odds ratio 4.6, 95% confidence interval 1.9-12.7, p = 0.002). After controlling for age, coma, and organ dysfunction, the presence of ESZs or PEDs was associated with death or severe disability at hospital discharge (89% with ESZs or PEDs, vs. 39% if not; odds ratio 19.1, 95% confidence interval 6.3-74.6, p < 0.001). In this retrospective study of MICU patients monitored with cEEG, ESZs and PEDs were frequent, predominantly in patients with sepsis. Seizures were mainly nonconvulsive. Both seizures and periodic discharges were associated with poor outcome. Prospective studies are warranted to determine more precisely the frequency and clinical impact of nonconvulsive seizures and periodic discharges, particularly in septic patients.

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