Clinical Fundamentals

& Applications of
aEEG
Judy Moore
Senior Clinical Marketing Manager, Natus NBC

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 Content Disclosure

 The educational materials presented here may be generic and/or product specific.
 It is the ultimate responsibility of a medical professional for complying with the product
labeling cleared by the regulatory agency for its intended use.
 Natus employees, agents, and staff make no representation or guarantee that these
compilations of information are error free and will bear no responsibility or liability for
the results or consequences of the use of these materials.
 These educational materials may include features that do not have regulatory clearance
in all regions of the world.

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 Objectives

• At the end of the presentation, the clinician will be able to:

– Describe the basic premise of aEEG and how it works
– Understand trace pattern nomenclature and qualifications for term
babies
– Describe the importance of using the raw EEG to validate the trace
– Describe Artifact and Impedance and how to reduce this

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 What is aEEG?

• aEEG is:
– 1, 2, or 3 channel bedside brain monitor
– Basic neurologic function trending tool
– Long-term monitoring capability
– Used to measure global electro-cortical activity
or specific site brain activity
– Developed by Neonatologists, for
Neonatologists
– Complimentary tool to quickly obtain
information regarding the baby’s neurological
status

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 What monitoring devices are used for
sick neonates in the NICU?

Heart Rate

Sa02 End Tidal

CO2

Respiratory

Blood
Temperature
Pressure

Photo by: omgigotablog09.blogspot.com

What about the BRAIN?

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 Monitoring Tools in the NICU

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 Monitoring Tools in the NICU
BEDSIDE HEART RATE MONITORING BEDSIDE BRAIN MONITORING
↓ ↓
3 lead ECG 3-5 lead aEEG
↓ ↓
Consultation - 12 lead ECG Consultation - Multi channel EEG

↓ ↓
Cardiac Echo Head Ultrasound

↓ ↓
Heart Cath Procedure MRI/CT

↓ ↓
Surgery Prognosis

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 What Do We Want to Know When We Monitor
the Brain with aEEG?
• What is the neurological status of the patient?
– Is there cerebral injury?
– What is the severity of the injury?
– What changes are occurring over time?
• Is there improvement or worsening of the neurological status
– What is the impact of NICU treatments to the patient’s brain function?
• Is the patient having seizures?
– What is causing the seizures?
– Are the seizures occurring more frequently, or for longer/shorter duration?
– Are the seizures responding to medical therapy?
• Is there electromechanical disassociation after medication?

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Who Can Be Monitored? | Clinical Applications
• Infants that have experienced a sentinel • Infants who are at higher risk for
event during delivery and are at risk for cerebral complications due to
hypoxic ischemic encephalopathy (HIE): circulatory instability
– Low Apgar – Sepsis
– Low pH – Hypoxia
– Required resuscitation or artificial ventilation at birth – Persistent pulmonary hypertension
– Poor tone/poor reflexes – Meconium aspiration
• Infants receiving hypothermia treatment – Cardiac malformations
for HIE – Diaphragmatic hernia
• Infants with definite or questionable • Additional clinical applications
seizures (clinical or subclinical): – Muscle relaxed/neuromuscular blockade
– Grade 3 or 4 IVH
• Infants with unexplained neurological – ELBW infants
symptoms (i.e. severe apnea) – Inborn errors of metabolism (e.g. urea cycle
disorders, hypoglycemia, hypocalcemia)
*Thoresen M, Hellstrom-Westas L, Liu X, de Vries L.
– Neonatal abstinence syndrome (e.g.
“Effect of Hypothermia on Amplitude-Integrated
Electroencephalogram in Infants With Asphyxia”.
alcohol/opiate withdrawal)
Pediatrics published online June 21, 2010; – Post surgical
DOI: 10.1542/peds.2009-2938
– Post cardiac arrest
– Infants requiring ECMO or surgery for CHD
NeoReviews Vol 7 No. 2
February 2006
Hellstrom-Westas, Rosen, deVries, Greisen

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 Breakdown - How Does aEEG Work?
• aEEG (“a”=amplitude integrated / EEG = electroencephalography):
– One, two, or three channels of EEG that go through a number
of modifications:
• special filtering
• rectification
• compression
• very slow, trend display
– aEEG is a process of taking a raw EEG, modifying it, and
producing a trending pattern that allows clinicians to measure
and view the microvoltage of the brain over time

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 Background Information - Channel

• Two electrodes are needed to create a single channel

• EEG waves reflect electrical voltage differences between
these two electrodes sites
– Measured in microvolts (µV)

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 aEEG Channels & the 10-20 System
• The Olympic Brainz Monitor may be used to monitor and record aEEG
patterns through either:

– Cross-Cerebral (default mode)

• 3 electrodes - 2 active & 1 hydrogel ground
• 1 aEEG channel (P3/P4)
• 1 EEG channel (P3/P4)

– Bilateral
• 5 electrodes – 4 active & 1 hydrogel ground
• 3 aEEG channels (C3/P3, C4/P4, P3/P4)
• 3 EEG channels (C3/P3, C4/P4, P3/P4)

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 Filtering

• The EEG signal is filtered 2–

15 Hz
• Specially shaped filter
• Reduces muscle and other
artifacts

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 Rectification

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 Compression

Log – 11-100 µVolts

Linear – 0 - 10 µVolts

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 Very Slow, Trend Display

3 hours

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 Amplitude-integrated EEG

raw EEG

Courtesy of K F Schettler

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 Amplitude-integrated EEG

Peak rectifier

Courtesy of K F Schettler

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 Amplitude-integrated EEG

filtering (2-15 Hz), smoothing

 Reduction of artifacts

Courtesy of K F Schettler

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 Amplitude-integrated EEG

Time compression

Courtesy of K F Schettler

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 Background Information - Margins

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 Background Information –
Sleep Wake Cycling (SWC) or Cyclicity
• Cyclicity characterized by:
– Smooth sinusoidal variations, mostly in the lower margin
– Broader bandwidth represents discontinuous background activity during quiet
sleep
– More narrow bandwidth corresponds to more continuous activity during
wakefulness and active sleep
– Quiet Sleep Cycle duration > 20 minutes
• Total SWC ~60-90 minutes

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 The Evidence –
Background Pattern Classification
Objectives After completing this article,
readers should be able to:
1. Understand the amplitude-integrated
electroencephalography (aEEG) method and
its
utility and limitations.
2. Classify and interpret typical aEEG
background patterns.
3. Identify epileptic seizure activity in the
aEEG.
4. Describe features in the aEEG recording that
are associated with prognosis.

e76 NeoReviews Vol.7 No.2 February 2006

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 aEEG Classification Framework
Feb 2006 – NeoReviews – Hellstrom Westas

Pattern Definition
Lower Margin Upper Margin
(Hellstrom-Westas
(in μV) (in μV)
& Toet)

Continuous
>5 >10
Normal Voltage
Discontinuous
<5 >10
Normal Voltage

>10 due to high

Burst Suppression <5
voltage bursts

Continuous
<5 <10
Low Voltage

Isoelectric/Flat <5 <5

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 aEEG and TERM Babies

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 Continuous Normal Voltage
• Sleep/Wake Cycling
• Upper Margin > 10 µVolts
• Lower Margin > 5 µVolts
• Limited Bandwidth Variability (between upper and lower margin)
– ~5-10 µVolts

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 Discontinuous Normal Voltage
• No Sleep/Wake
• Upper Margin > 10 µVolts
• Lower Margin < 5 µVolts
• Increased Bandwidth Variability
– ~30 – 40 µVolts

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 Burst Suppression
• No Sleep Wake Cycling
• Upper margin >10μV (due to high voltage bursts)
• Lower margin <5μV
• Limited variability of lower margin

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 Continuous Low Voltage
• No Sleep/Wake Cycling
• Upper margin <10uV
• Lower margin <5uV

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 Isoelectric or Flat
• No Sleep/Wake
• Upper Margin < 5 µVolts
• Greatly reduced bandwidth variability
– ~1 µVolt

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 Seizure EEG

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 Status Epilepticus

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Olympic Brainz Monitor
Introducing RecogniZe for the Olympic Brainz Monitor

Product Description: OBM RecogniZe SW

The Olympic Brainz Monitor RecogniZe
module incorporates a patented,
proprietary seizure detection algorithm
that detects events that may correspond
with seizure activity in a patient.
- Alerts bedside clinicians to areas of aEEG/EEG that
require review and may need more attention by the
clinical staff
- A trained clinician can then review marked sections of the
EEG trace and quickly confirm activity that may be
interpreted as a seizure

NOTE: The Olympic Brainz Monitor RecogniZe product does not provide any
diagnostic indication of the patient’s condition.
 Continuous Normal Voltage

Discontinuous Normal Voltage

Burst Suppression

Continuous Low Voltage

Isoelectric

Seizures

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OBM BPc SW Option
Introducing THE ONLY Neonatal Background Pattern
Classification Algorithm available

Expanding the utility

OBM BPc SW of aEEG Monitoring
Along with detection of sub-clinical seizure
identification now the OBM can also provide
feedback on changes to the background
pattern to assist during cooling or other
monitoring scenarios.
Background Pattern Classification BPc

For Internal Use Only - Do

 Impedance and Artifact
• Impedance
– A measure of the quality of electrode contact
– Anything that gets between the sensor (hydrogel or low impedance
needles) and “impedes” or interferes with the devices ability to read
the brain signal (hair, dry skin, vernix)

• Artifact
– Any electrical activity other than the brain’s electrical activity
(monitors, IV pumps, ventilators, etc.)
– Live EEG signal is used as a point of reference to confirm suspected
brain activity OR to distinguish artifact from the real signal

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Causes of aEEG Artefacts:
• Other Electrical interference (in environment of
physiological)
• Poor sensor application impedance
• Medications
• Movement (including Shivering)
• Respiratory
• Patting
• Oedema or Haematoma
Hagmann et al., Pediatrics 2006, 118:2552-4
Always Check Impedance Signal
before and during recording
 ECG Artifact

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 • CFMSight™ - Grey Scale
– Enhanced signal display to allow
clinician easier signal
interpretation and artifact
detection
– Trace appears normal without
CFMSight™
– Same trace with CFMSight™
clearly shows a burst suppression
pattern
• Most likely artificially elevated by
ECG artifact

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 aEEG Limitations
Influence of sedative/analgetic/
anticonvulsivemedication
• transient
• can be influenced

HJ ter Horst et al., Acta Apediatrica, 2004

HJ Niemarkt et al., Acta Paediatrica, 2008
GB Young et al., Clin Neurophysiol, 2000
aEEG can also be affected by

– Stimulating substances (methyxanthines)

– Blood pressure
– Sepsis
– Acidosis, Glucose

and much more…

Infant at age 2 days, born at 24 weeks GA
Depressed tracing: pH, 6.84; pCO2 105 mm Hg
Supcun et al., J Pediatr. 2010 Normal tracing pH, 7.14; pCO2 44 mm Hg
Greisen G et al, Acta Paeditr Scand 1988
Helderman JB et al., Early Hum Dev. 2010
Granot S et al, Eur J Pediatr 2012
aEEG Limitations

aEEG is cortical activity

Infants with lesions within

basalganglia/thalamus and only
little cortical involvement
cannot be identified by aEEG
alone
 Associations of short-term outcome (MRI)

Requires Resus

Apgar @ 5min<6

BE<-14.9

Seizures OR

sarnat 2&3

aEEGBRM2 (abn)

BRM2 & Sarnat

aEEG

0 2 4 6 8 10 12 14
Odds Ratio

Lavery et al,2006, abstract-PSANZ

 How many Channels?

28 patients with simultaneous 1 and 2 channel aEEG

MRI for identifying cerebral damage and Neurological outcome after 2 years
- in 4 cases normal 1-channel-aEEG and abnormal 2-channel-aEEG
- all 4 had severe abnormal MRI and bad neurological outcome
Lavery, Shah, Hunt, Filan, Doyle, Inder:
Single versus bihemispheric amplitude-integrated EEG in relation to cerebral injury and outcome in the term encephalopathic infant. J Pediatr
Child Health, 2008 May; 44(5):285-90
 aEEG Reference Literature

Atlas of Amplitude-Integrated EEGs in the

www.neonatalcareacademy.com Newborn: Second Edition (Hellstrom-
Westas, De Vries, Rosen; 2008)

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aEEG Trace
Interpretation
Quiz
What does this aEEG Trace show?
1. Continuous Normal Voltage
2. Discontinuous Normal
voltage
3. Burst Suppression
4. Continuous Low Voltage
5. Isoelectric/flat trace
Is there Cyclicity in the Trace?
1. Yes
2. No
3. Not sure
Do you see Seizure activity?

A. No Seizures
B. Single Seizures
C. Multiple Seizures
D. Status Epilepticus
E. Not sure
What does this aEEG Trace show?
A. Continuous Normal Voltage
B. Discontinuous Normal
voltage
C. Burst Suppression
D. Continuous Low Voltage
E. Isoelectric/flat trace
Is there Cyclicity in the Trace?

A. Yes
B. No
C. Not Sure
Do you see Seizure activity?
A. No Seizures
B. Single Seizures
C. Multiple Seizures
D. Status Epilepticus
E. Not sure
What does this aEEG Trace show?
A. Continuous Normal Voltage
B. Discontinuous Normal
voltage
C. Burst Suppression
D. Continuous Low Voltage
E. Isoelectric/flat trace
Is there Cyclicity in the Trace?

A. Yes
B. No
C. Not sure
Do you see Seizure activity?
A. No Seizures
B. Single Seizures
C. Multiple Seizures
D. Status Epilepticus
E. Not sure
 Thank You! www.neonatalcareacademy.com

facebook.com/neonatalcareacademy
scan to register twitter.com/nca4you www.natus.com

Natus Medical Incorporated

1501 Industrial Rd
San Carlos, CA 94070 USA
1-800-303-0306
1-650-802-0400
www.natus.com
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aEEG in the HIE Infant

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 Outcome Prediction Using aEEG:

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 – Reappearance of SWC within 36
h gives a good prognosis in
normothermic infants
– In hypothermic infants, the
reappearance of SWC could be as
late as 60 h in infants who
developed normally
– Time to normal trace (TTNT) is a
better predictor than time to
normal SWC appearence
• never achieving SWC always predicts
poor outcome

Thorasen. Pediatrics 2010

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 The background pattern and voltage classifications at 3 to 6 hours are presented regarding infants’ treatments and
outcomes at 18 months. Three voltage
classifications (normal, moderately abnormal, and severely abnormal) are plotted against 5 background patterns
(CNV, DNV, BS, LV, and FT).

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 Prognostic Tests in Term infants with HIE
CONCLUSIONS: This evidence suggests an
important role for amplitude integrated
electroencephalography, EEG, visual
evoked potentials, and diffusion weighted
and conventional MRI.

EEG and aEEG both perform well in

predicting outcome for neonates with
perinatal asphyxia and HIE even when
performed in the first week of life. MRI is
generally advised between the fourth
and the eighth day after HIE. This time
window is clinically essential to evaluate
brain damage

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Pediatrics 2013;131:88–98
aEEG in the
Preterm Infant

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 What is Normal for the Preterm Infant?

• Extrauterine life is not a

normal condition
• In preterm infants, data on
normal postnatal
development of
EEG/aEEG/EP in extremely
preterm infants are difficult
to obtain http://www.hmhb.org/2013/12/2013-year-promise-healthy-moms-babies/

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 Factors affecting aEEG/EEG in very preterm infants

• Maturation (gestational age and postnatal age)

• Brain injury (IVH, PVL)
• Medications (sedatives, surfactant)
• Carbon dioxide level
• Glucose level
• Blood pressure

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 aEEG/EEG in preterm infants is also affected by:

• Medications (surfactant, diazepam, morphine,

sufentanil, phenobarbital)
• Cerebral blood flow (Greisen et al 1988, 1989)
• Cardiac output – blood pressure (Benders et al 2000, West
et al 2006, Victor et al 2006)
• Carbon dioxide level (Eaton et al 1994, Victor et al 2005,
Wikström et al 2011)
• Hypoglycaemia (Wikström et al 2011)
• Infection/sepsis (Helderman et al 2010)

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 The dominating background activity
is discontinuous
with periods of high voltage activity (burst) and periods of
low amplitude (interburst interval)

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 24 weeks GA

Maturation
Some maturational features
can be considered normal at 30 weeks GA
some gestational ages, but
abnormal if present at later
stages

(a)EEG becomes more 38 weeks GA

continuous with increasing
maturation, interburst
intervals become shorter

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 Extra- versus intrauterine maturation
For unknown reasons, background activity seems to increase and become
more continuous during the first days of life
West CR et al, Early Hum Dev 2006

Maturation of aEEG background is described as accelerated as compared

with more mature infants at equivalent postmenstrual age

Sisman J et al, J Perinatol 2005

Klebermass K et al, Biol Neonat 2006
Herbertz S et al, Acta Paediatrica 2006
Soubasi V et al, Early Human Dev 2009

http://www.rrnursingschool.biz/nervous-system/figure-67.html
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 Amplitude-integrated EEG Classification and Interpretation in Preterm and Term
Infants
NeoReviews. Vol 7 No. 2 February 2006
Hellstrom-Westas, Rosen, deVries, Greisen

Gestational or Dominating SWC Minimum Maximum Burst/h

Postconceptual Background Amplitude (mcV) Amplitude (mcV)
Age (wk) Pattern
24 through 25 DC (+) 2 to 5 25 to 50 (to 100) >100

26 through 27 DC (+) 2 to 5 25 to 50 (to 100) >100

28 through 29 DC/(C) (+)/+ 2 to 5 25 to 30 >100

30 through 31 C/(DC) + 2 to 6 20 to 30 > 100

32 through 33 C/DC in QS + 2 to 6 20 to 30 > 100

34 through 35 C/DC in QS + 3 to 7 15 to 25 >100

36 through 37 C/DC in QS + 4 to 8 17 to 35 > 100

38+ C/DC in QS + 7 to 8 15 to 25 > 100

SWC: (+) = imminent/immature; SWC: + = developed; SWC: QS = quiet/deep sleep;

DC = discontinuous background pattern; (C) = continuous
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 Reference Values for aEEG Activity in
infants <30ks gestation

• Normal values for aEEG background activity

were determined in preterm infants <30
weeks’ GA.
• Clinically stable and neurologically normal
preterm infants exhibit at least 2 different
patterns of aEEG activity.
• There is a correlation between the GA and
the relative duration of continuous aEEG
activity.

Monika Olischar, Katrin Klebermass, et al

Pediatrics 2004;113;e61
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 Burst suppression pattern discontinuous pattern

The 3 observed types of aEEG patterns in a patient of 28 2 weeks’ GA (the period

between 2 vertical bars corresponds to 10 minutes).

Monika Olischar, Katrin Klebermass, et al

Pediatrics 2004;113;e61

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 Predicting outcome with aEEG in very preterm infants

Results: 30 Infants had good outcome. Poor outcome (n

= 19) was associated with depressed aEEG ⁄ EEG already
during the first 12 h (p = 0.023), and with prolonged
IBI and higher IB% at 24 h. Seizures were present in 43%
of the infants and associated with IVH but not with
outcome. Best predictors of poor outcome were burst-
suppression pattern IBI > 6 sec and IB% > 55% at 24 h
age In 35 infants with normal cerebral ultrasound
during the first 3 days, outcome was correctly predicted
in 82% by IB%

Conclusion: Long-term outcome can be predicted by

aEEG ⁄ EEG with 75–80% accuracy already at 24
postnatal hours in VPT infants, also in infants with no
early indication of brain injury.
Sverre Wikström et al
Acta Pædiatrica 2012 101, pp. 719–726

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 aEEG in preterm infants – Prognostic value?

Data shows that one aEEG recording

obtained within the first 2 wks of life
(optimally obtained without any
sedative/analgetic/anticonvulsive
Outcome 3 aEEG aEEG Existing
yrs normal normal abnormal SWC medication) predicts further outcome in
preterm infants with a specificity of
N=61 93% 7% 98% 98%, sensitivity of 61%, PPV of 96%.
(57/61) (4/61) (60/61)
Thus, we can underline the usefulness
of this method also for preterm infants
Outcome 3 aEEG aEEG Existing born <30 wk GA and enhance early
yrs impaired normal abnormal SWC
functional neurophysiological
assessment.
N=82 18% 82% 28%
(15/82) (67/82) (23/82)

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 Sensitivity 83%
Specificity 95%

best in week 2

better than cerebral ultrasound…

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 aEEG in Intra-/Periventricular Haemorrhage

aEEG background becomes:

- more discontinuous during

first days of life in infants
developing IVH and
- the depression correlates
with the degree of IVH

Olischar, M. et al Background patterns and sleep-wake cycles on amplitude-integrated electroencephalography in

preterms younger than 30 weeks gestational age with peri-/intraventricular haemorrhage. Acta
Paediatr. 2007;96:1743–1750
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 aEEG and White matter injury

aEEG during first days of life

shows association between
development of cerebral
echodensities, early amplitude
depression and the presence
of seizure activity,mainly
subclinical.
Hellström-Westas et al., Neuropediatrics 1991

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aEEG in Cardiac
and Surgical
Infants

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 Outcomes:
• Outcome following cardiac surgery
• Increased risk of
neurodevelopmental impairment
• Brain injury
• White matter injury and stroke
like lesions 38% 45%

• Outcome following non-cardiac 26% 26%

surgery
• Impairment in motor function Walker et al J Pediatr 2012

• Cognitive impairment

Laing et al J Paediatr Child Health 2011

Walker et al J Pediatr 2012
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 Risk of neonatal brain damage
• Transition from fetal life
• Immaturity of organ systems
– Hypoxic/ischemic damage
– Hyperoxic damage
• Neurotoxicity anesthetics

Monitoring vital parameters:

(HR, BP, SaO2, pCO2, Hb, etCO2)

• No direct information
• Cerebral oxygenation
• Brain Perfusion
http://www.witspaedsurg.co.za/for-patients/neonatal-surgery/

• Brain activity
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aEEG and Hypercapnia
• Extreme fluctuations in PaCO2 and a higher
maximum PaCO2 have been associated with worse
neurodevelopmental outcome in very low birth
weight preterm infants. This may be mediated
through the induction of brain damage such as
intracranial haemorrhage and periventricular
leukomalacia. Prolonged depression of cortical
function has been associated with impaired
outcome in preterm infants. However, the EEG
depression in CO2 narcosis is reversible and should
therefore be corrected as soon as possible.
• In conclusion, acute hypercapnia can cause
reversible depression of the aEEG background
activity, without clinically detectable changes in
cerebral oxygenation and other haemodynamic
parameters in infants. A sudden depression in the
aEEG background activity in these infants should
alert clinicians to suspect a high PaCO2 due to a
respiratory problem.
0.1136/archdischild-2016-311770
 Ventilation : pCO2

Brain monitoring during (artificial) ventilation can help to prevent hypo/hyper

perfusion and hyper/hypoxemia and so brain damage
Toet/ de Vries
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 PDA and Brain Volume

This study group found that surgical

ductal closure had undesirable effects
on cerebral oxygenation and blood
pressure. It might be that monitoring
blood pressure, monitoring electrical
brain activity with aEEG, NIRS
monitoring of cerebral oxygenation
may prevent or reduce these side
effects of surgical closure

PEDIATRICS Volume 137, number 4, April 2016: e 20153090

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 aEEG In Newborns with Critical CHD predicts
Preoperative Brain MRI findings

 Newborns with congenital heart disease

(CHD) who require surgery during the
neonatal period are at risk for early brain
injury, with up to 50% having brain injury on
preoperative brain MRI
 Methods to identify brain injury and predict
neurodevelopmental outcomes using
noninvasive neurodiagnostic tests could
improve clinical care of these newborns.
 In addition, recent guidelines by the
American Clinical Neurophysiology Society
recommend long-term EEG monitoring in
infants with CHD that require early surgery

S.B. Mulkey et al. / Pediatric Neurology xxx (2015) 1e7

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 Mulkey S.B. et al:
aEEG In Newborns with Critical CHD predicts Preoperative Brain MRI findings

Aim: To evaluate cerebral background patterns

using aEEG in newborns with CHD and
determine if aEEG is predictive of preoperative
brain injury and assess the incidence of
preoperative seizures
Conclusions:
Background cerebral activity is abnormal on
amplitude-integrated electroencephalography
following birth in newborns with congenital
heart disease that have findings of brain injury
and/or brain atrophy on preoperative brain
magnetic resonance imaging.

S.B. Mulkey et al. / Pediatric Neurology xxx (2015) 1e7

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  An abnormal aEEG background pattern correlates with brain injury on
preoperative brain MRI and a severely abnormal aEEG background pattern
is associated with brain atrophy. This is the first study to correlate an early
abnormal aEEG and brain injury detected on MRI in newborns with CHD
that require neonatal surgery.
 These findings are important because routine neuromonitoring with aEEG is
not performed as a standard procedure in newborns with CHD that have
surgery as neonates. Finding abnormal background aEEG patterns, even in
this limited time frame before surgery, can provide relevant information
about the infants’ neurological status that may correlate with
neurodevelopmental outcome.
 In conclusion, aEEG abnormalities are detected in newborn infants with CHD
and this correlates with brain injury and brain atrophy on preoperative MRI.
The ability of a noninvasive and real-time neurodiagnostic test to inform
about brain imaging abnormalities in newborns with CHD may enable
improved neurological focused preoperative clinical care that can hopefully
lead to improved long-term neurodevelopmental outcomes.

S.B. Mulkey et al. / Pediatric Neurology xxx (2015) 1e7

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 aEEG and Brain Injury in Infants undergoing
Norwood-Type Operations
Perioperative brain injury is common in
infants undergoing cardiac surgery. aEEG provides realtime
neurologic monitoring and can identify seizures and
abnormalities of background cerebral activity
Aims: To determine the incidence of perioperative seizures
using aEEG before, during, and for 72 hours after surgery, to
ascertain the typical period of aEEG recovery in neonates
undergoing Norwood-type
palliations
Conclusions. Subclinical electrical seizures are common in
neonates undergoing Norwood-type operations, both
during and after surgery. Delayed recovery in aEEG
background was associated with increased risk of early
mortality and worse motor development.
A prolonged aEEG recovery phase is associated with
increased mortality and impaired motor development
at 2 years of age in survivors

Ann Thorac Surg 2012;93:170–6)

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 Effect of Medications on aEEG post surgery

 There is increasing evidence of

neurodevelopmental impairment in
survivors of non-cardiac surgery
 Sleep characteristics have been reported
as predictors of neurodevelopmental
outcome and indices of stability in SWC
over time are positively correlated with
improved clinical outcome
 The aim of this prospective observational
study was to explore the influence of
analgesic and sedative medication on
aEEG in newborns born >32 weeks’
gestation after major non-cardiac surgery.

Neonatology 2012;101:293–300

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 Findings and Outcomes:
 There was no evidence that the maximum
dose of morphine or midazolam infusion
influences time to emergence of SWC in
neonates born >32 weeks’ gestational age
who underwent major non-cardiac surgery
 Despite relatively high-dose continuous
infusions of morphine and midazolam, SWC
was observed on aEEG in neonates >32
weeks’ gestational age soon after major non-
cardiac surgery.
 Age-appropriate background activity and
well-established SWC are thought to be
indicators of intact cerebral activity.
 We believe aEEG monitoring has a role in the
monitoring of post-surgical patients in the
NICU who remain at risk of longer-term
neurodevelopmental impairment.
Neonatology 2012;101:293–300

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 Non-Conventional use of aEEG – Lessons from a
Tertiary NICU  The ability to monitor global cerebral brain
activity is increasingly being recognized as an
essential component of neonatal intensive
care
 It is known that critically ill neonates with
acute cardiovascular compromise due to CHD
or PPHN are at increased risk of abnormal
neurodevelopmental outcome; however,
continuous neurological monitoring in these
“at risk” populations is usually not performed
 An improved understanding of the
relationship between tissue oxygenation or
organ perfusion and dynamic measures of
cerebral performance may facilitate earlier
detection of “at risk” scenarios which may be
conducive to interventions.

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 A recent study of aEEG monitoring in neonates
with CHD requiring surgery demonstrated
abnormal background activity in 53% of
neonates. Although background
activity improved by discharge, in some patients
a severely abnormal aEEG trace predicted death
or intracranial neuropathology with a sensitivity
of 1.0 (0.85-1.0) and specificity of 0.75
(0.52-0.75).
In a small review of 30 non-asphyxiated neonates
admitted to our NICU with a diagnosis of PPHN or
CHD, an abnormal aEEG trace was identified in
50% cases The long term significance of this
finding remains unknown. However, in patients
with abnormal aEEG where MRI of brain
was performed (n=5) all but one had abnormal
findings that are known to be associated with
poor neurodevelopmental outcome. aEEG may
certainly, at least, guide selection of patients for
more detailed neuroimaging and
neurodevelopmental follow-up.
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