Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study

Urs Fisch, Anja L Jünger, Sira M Baumann, Saskia Semmlack, Gian Marco De Marchis, Sabina Hunziker, Stephan Rüegg, Stephan Marsch, Raoul Sutter, Urs Fisch, Anja L Jünger, Sira M Baumann, Saskia Semmlack, Gian Marco De Marchis, Sabina Hunziker, Stephan Rüegg, Stephan Marsch, Raoul Sutter

Abstract

Background and objectives: To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE).

Methods: Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints.

Results: We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005).

Discussion: In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.

Conflict of interest statement

U. Fisch, A.L. Jünger, S.M. Baumann, and S. Semmlack report no disclosures. G.M. De Marchis has been receiving support from the Swiss National Science Foundation (numbers 32003B_200573 and PBBEP3_139388); Spezialprogramm Nachwuchsförderung Klinische Forschung, University of Basel; Science Funds (Wissenschaftspool) of the University Hospital Basel; Swiss Heart Foundation; ProPatient Foundation Basel; Bangerter-Rhyner-Stiftung; Swisslife Jubiläumsstiftung for Medical Research; Swiss Neurological Society; Fondazione Dr Ettore Balli; De Quervain research grant; Thermo Fisher GmbH; and Novartis grant; travel honoraria by Bayer and BMS/Pfizer; speaker honoraria by Bayer and Medtronic; and consultant honoraria by Bayer and Novartis. He is a member of the Steering Committee of PACIFIC Stroke (NCT04304508). Industry payments are made to the research fund of the University Hospital Basel. S. Hunziker is supported by the Swiss National Foundation (SNF) (Ref 10001C_192850/1 and 10531C_182422), the Gottfried Julia Bangerter-Rhyner Foundation (8472/HEG-DSV), and the Swiss Society of General Internal Medicine (SSGIM). S. Rüegg received unconditional research grants from UCB-pharma. He received honoraria from serving on the scientific advisory boards of Angellini/Arvelle, Bial, Eisai, GW, and UCB-pharma and from serving as a consultant for Angellini/Arvelle, Eisai, Pfizer, Novartis, Sandoz, and UCB-pharma. He does not hold any stocks of any pharmaceutical industries or manufacturers of medical devices. He received funding from UCB-pharma and Swiss National Science Foundation Grants: grant number 320030_169379/1 and coapplicant for grants numbers 33CM30_125115/1 and 33CM30_140338/1; he disclosed that he is the past president of the Swiss League Against Epilepsy (no payments), Editor of Zeitschrift für Epileptologie (Journal of the German, Austrian, and Swiss League Against Epilepsy) (no payments). S. Marsch reports no disclosures. R. Sutter received research grants from the Swiss National Foundation (number 320030_169379), the Research Fund of the University Basel, the Scientific Society Basel, and the Gottfried Julia Bangerter-Rhyner Foundation. He received personal grants from UCB-pharma and holds stocks from Novartis, Roche, Alcon, and Johnson & Johnson. Go to Neurology.org/N for full disclosures.

© 2023 American Academy of Neurology.

Figures

Figure 1. Semiquantification of Burst Suppression
Figure 1. Semiquantification of Burst Suppression
Within 2-minute epochs, suppression/attenuation segments were visually identified and rounded to whole seconds (bold lines): Absence of any burst suppression pattern (A, ≤20% cumulative suppression/attenuation segments of an exemplary 15-second EEG epoch); incomplete burst suppression (B, ≥20% and

Figure 2. Flowchart and EEG Characteristics Among…

Figure 2. Flowchart and EEG Characteristics Among the Subgroups of the Study Population

(A) Proportion…

Figure 2. Flowchart and EEG Characteristics Among the Subgroups of the Study Population
(A) Proportion of patients with and without achieved burst suppression during the treatment of refractory status epilepticus. (B) Proportion of patients with and without complete or incomplete burst suppression among specific subgroups. NCSE = nonconvulsive status epilepticus; RSE = refractory status epilepticus; SE = status epilepticus; STESS = Status Epilepticus Severity Score.
Figure 2. Flowchart and EEG Characteristics Among…
Figure 2. Flowchart and EEG Characteristics Among the Subgroups of the Study Population
(A) Proportion of patients with and without achieved burst suppression during the treatment of refractory status epilepticus. (B) Proportion of patients with and without complete or incomplete burst suppression among specific subgroups. NCSE = nonconvulsive status epilepticus; RSE = refractory status epilepticus; SE = status epilepticus; STESS = Status Epilepticus Severity Score.

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