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July 2008 Issue

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University Hospital Making Strides in Neuroscience ICU

Published July 2008

People hear the word "seizure," says Lori Shutter, MD, and immediately think of a person writhing on the floor, flailing his limbs.

Some seizures are like that, of course, but with the help of continuous EEG monitoring Shutter and her colleagues at the Neuroscience Intensive Care Unit (NSICU) in University Hospital are gaining insight into seizures as fleeting as the twitch of an eye.

Shutter, associate professor of neurosurgery and neurology at UC and director of the NSICU/Neurocritical Care Program at University Hospital, oversees the 20 NSICU beds. And the program, already the largest in the state, is poised to grow even larger and enhance its national stature.

"We have approval from University Hospital to expand to 28 beds," says Shutter. "That will make us one of the largest neuroscience ICUs in the country."

The NSICU at University Hospital is dual-licensed, which means that every bed is licensed for both ICU and step-down levels of care.

"Instead of patients having to move out of an ICU bed," says Shutter, "with step-down they get to stay in their room, families get to stay where theyíre familiar, and they see familiar nurses. All we do is change the nursing ratio."

A typical ratio for an ICU bed is one nurse for two beds; in a step-down, itís one nurse for three beds.

Some of the most intriguing cases in the NSICU involve patients who are not awake and able to respond to commands. With continuous EEG (a record of the tiny electrical impulses produced by the brainís activity), Shutter and her colleagues hope to identify non-convulsive seizures and treat them with the appropriate medication.

"We donít know if treating the non-convulsive seizures will actually change someoneís outcome," says Shutter, "but we do know that seizures can delay recovery and may slow down the process of getting somebody to rehabilitation.

"And thatís one of the reasons that programs like ours need to focus on collecting this information," she says.

"The only way you can know if itís really worthwhile to collect this information and aggressively treat these seizures is to prove that treatment will result in an improved outcome for our patient."

Historically, according to Shutter, it was thought that about 10 percent of patients who were not awake in an ICU were having seizures. New data suggests that the number ranges from 25 to 30 percent, she says.

"So that means that one out of three to four of our patients who are not responding to us may be having seizures," she says, "and over half of those may be something called non-convulsive seizures where you donít see the shaking that people associate with seizures."

Epilepsy patients represent the highest potential for seizures and therefore can be placed on continuous EEG monitoring in the NSICU, Shutter says, but there are other categories such as head trauma, bleeding in the brain and brain tumor patients who arenít responsive following surgery.

Those numbers are slightly lower, she says, but still probably around 20 to 25 percent.

"Thatís another thing thatís unique about our program," says Shutter. "The current places in the country that are doing continuous EEG tend to be geared toward one disease.

"Weíre one of the few places that have relatively equal numbers of head trauma, hemorrhagic stroke, aneurysm hemorrhage and epilepsy."

Monitoring is about to become more efficient, Shutter says, with the arrival of EEG machines with data processing capabilities.

With the new machines, which compress the data, a 24-hour period can be scanned far more quickly.

"You can see changes in the processed EEG by frequency changes, spike wave detection and other things that pop up as markers of seizure activity," Shutter says.

"Itís basically saying to the epileptologist, ĎHey, look here,í and then they can blow up that segment and look at it in more detail."

With all the time, energy and technology involved, it can be jarring to hear Shutter say, "We donít know if information gained through continuous EEG enhances recovery."

But, she points out, "You canít just ignore the fact that one-third to one-fourth of all your patients may be having uncontrolled seizures.

"And in many of our patientsó the majority of themówe would never have known it without the continuous EEG."

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