Myoclonus in comatose patients with electrographic status epilepticus after cardiac arrest: Corresponding EEG patterns, effects of treatment and outcomes

Sjoukje Nutma; Barry J Ruijter; Albertus Beishuizen; Selma C Tromp; Erik Scholten; Janneke Horn; Walter M van den Bergh; Vivianne Hjm van Kranen-Mastenbroek; Elsbeth C Thomeer; Walid Moudrous; Marcel Aries; Michel Jam van Putten; Jeannette Hofmeijer; TELSTAR Investigators

doi:10.1016/j.resuscitation.2023.109745

Myoclonus in comatose patients with electrographic status epilepticus after cardiac arrest: Corresponding EEG patterns, effects of treatment and outcomes

Resuscitation. 2023 May:186:109745. doi: 10.1016/j.resuscitation.2023.109745. Epub 2023 Feb 22.

Collaborators

TELSTAR Investigators:
P Noordzij¹², H Moeniralam¹², A Seeber¹³, M Datema¹³, A F van Rootselaar¹⁴, M M Admiraal¹⁵, D C Velseboer¹⁵, J H Koelman¹⁴, J W J Elting¹⁶, G Drost¹⁶, N Foudraine¹⁷, F Kornips Md¹⁸, R Rouhl¹⁹, D M W Hilkman¹⁹, W van Mook²⁰, M Vlooswijk¹⁹, F Nijhuis²¹, S Booij²¹, H Bernsen²¹, A Hoedemaekers²², J Doorduin²², F Taccone²³, N Gaspard²⁴, S C Tromp²⁵

Affiliations

¹ Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands. Electronic address: s.nutma@mst.nl.
² Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands.
³ Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands.
⁴ Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands.
⁵ Department of Critical Care, St Antonius Hospital, Nieuwegein, the Netherlands.
⁶ Department of Critical Care, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands.
⁷ Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁸ Department of Critical Care, Maastricht University Medical Center, Maastricht, the Netherlands.
⁹ Department of Neurology and Clinical Neurophysiology, Maasstad Hospital, Rotterdam, the Netherlands.
¹⁰ Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands.
¹¹ Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands.
¹² Department of Critical Care, Antonius hospital, Nieuwegein, The Netherlands.
¹³ Department of Neurology, Antonius hospital, Nieuwegein, The Netherlands.
¹⁴ Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
¹⁵ Department of Critical Care, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
¹⁶ Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands.
¹⁷ Department of Critical Care, VieCuri Medical Center, Venlo, the Netherlands.
¹⁸ Department of Neurology, VieCuri Medical Center, Venlo, the Netherlands.
¹⁹ Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.
²⁰ Department of Critical Care, Maastricht University Medical Center, Maastricht, The Netherlands.
²¹ Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
²² Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.
²³ Department of Critical Care, Université Libre de Bruxelles, Brussels, Belgium.
²⁴ Department of Neurology, Université Libre de Bruxelles, Brussels, Belgium.
²⁵ Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.

PMID: 36822459
DOI: 10.1016/j.resuscitation.2023.109745

Abstract

Objective: To clarify the significance of any form of myoclonus in comatose patients after cardiac arrest with rhythmic and periodic EEG patterns (RPPs) by analyzing associations between myoclonus and EEG pattern, response to anti-seizure medication and neurological outcome.

Design: Post hoc analysis of the prospective randomized Treatment of ELectroencephalographic STatus Epilepticus After Cardiopulmonary Resuscitation (TELSTAR) trial.

Setting: Eleven ICUs in the Netherlands and Belgium.

Patients: One hundred and fifty-seven adult comatose post-cardiac arrest patients with RPPs on continuous EEG monitoring.

Interventions: Anti-seizure medication vs no anti-seizure medication in addition to standard care.

Measurements and main results: Of 157 patients, 98 (63%) had myoclonus at inclusion. Myoclonus was not associated with one specific RPP type. However, myoclonus was associated with a smaller probability of a continuous EEG background pattern (48% in patients with vs 75% without myoclonus, odds ratio (OR) 0.31; 95% confidence interval (CI) 0.16-0.64) and earlier onset of RPPs (24% vs 9% within 24 hours after cardiac arrest, OR 3.86;95% CI 1.64-9.11). Myoclonus was associated with poor outcome at three months, but not invariably so (poor neurological outcome in 96% vs 82%, p = 0.004). Anti-seizure medication did not improve outcome, regardless of myoclonus presence (6% good outcome in the intervention group vs 2% in the control group, OR 0.33; 95% CI 0.03-3.32).

Conclusions: Myoclonus in comatose patients after cardiac arrest with RPPs is associated with poor outcome and discontinuous or suppressed EEG. However, presence of myoclonus does not interact with the effects of anti-seizure medication and cannot predict a poor outcome without false positives.

Keywords: Anti-seizure medication; EEG; Hypoxic-ischemic encephalopathy; Myoclonus; Neuroprotection; Post cardiac arrest syndrome; Resuscitation.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Coma / complications
Coma / therapy
Electroencephalography
Heart Arrest* / complications
Heart Arrest* / therapy
Humans
Myoclonus* / complications
Myoclonus* / therapy
Prospective Studies
Status Epilepticus* / complications
Treatment Outcome