Treating rhythmic and periodic EEG patterns in comatose survivors of cardiac arrest

Ruijter, B.J.; Keijzer, H.M.; Tjepkema-Cloostermans, M.C.; Blans, M.J.; Beishuizen, A.; Tromp, S.C.; ... ; TELSTAR Investigators (2022)

Article / Letter to editor

BACKGROUNDWhether the treatment of rhythmic and periodic electroencephalographic (EEG) patterns in comatose survivors of cardiac arrest improves outcomes is uncertain.METHODSWe conducted an open-label trial of suppressing rhythmic and periodic EEG patterns detected on continuous EEG monitoring in comatose survivors of cardiac arrest. Patients were randomly assigned in a 1:1 ratio to a stepwise strategy of antiseizure medications to suppress this activity for at least 48 consecutive hours plus standard care (antiseizure-treatment group) or to standard care alone (control group); standard care included targeted temperature management in both groups. The primary outcome was neurologic outcome according to the score on the Cerebral Performance Category (CPC) scale at 3 months, dichotomized as a good outcome (CPC score indicating no, mild, or moderate disability) or a poor outcome (CPC score indicating severe disability, coma, or death). Secondary outcomes were mortality, length of stay in the intensive care unit (ICU), and duration of mechanical ventilation.RESULTSWe enrolled 172 patients, with 88 assigned to the antiseizure-treatment group and 84 to the control group. Rhythmic or periodic EEG activity was detected a median of 35 hours after cardiac arrest; 98 of 157 patients (62%) with available data had myoclonus. Complete suppression of rhythmic and periodic EEG activity for 48 consecutive hours occurred in 49 of 88 patients (56%) in the antiseizure-treatment group and in 2 of 83 patients (2%) in the control group. At 3 months, 79 of 88 patients (90%) in the antiseizure-treatment group and 77 of 84 patients (92%) in the control group had a poor outcome (difference, 2 percentage points; 95% confidence interval, -7 to 11; P=0.68). Mortality at 3 months was 80% in the antiseizure-treatment group and 82% in the control group. The mean length of stay in the ICU and mean duration of mechanical ventilation were slightly longer in the antiseizure-treatment group than in the control group.CONCLUSIONSIn comatose survivors of cardiac arrest, the incidence of a poor neurologic outcome at 3 months did not differ significantly between a strategy of suppressing rhythmic and periodic EEG activity with the use of antiseizure medication for at least 48 hours plus standard care and standard care alone. (Funded by the Dutch Epilepsy Foundation; TELSTAR ClinicalTrials.gov number, TELSTAR ClinicalTrials.gov number, NCT02056236.)Treatment of Epileptiform Activity after Cardiac Arrest A trial involving comatose survivors of cardiac arrest tested whether aggressively treating rhythmic and periodic EEG activity would improve neurologic outcomes. Despite suppression of abnormal EEG activity, the incidence of a poor neurologic outcome did not differ significantly from that with standard care, and mortality was high.

• All authors: Ruijter, B.J.; Keijzer, H.M.; Tjepkema-Cloostermans, M.C.; Blans, M.J.; Beishuizen, A.; Tromp, S.C.; Scholten, E.; Horn, J.; Rootselaar, A.F. van; Admiraal, M.M.; Bergh, W.M. van den; Elting, J.W.J.; Foudraine, N.A.; Kornips, F.H.M.; Kranen-Mastenbroek, V.H.J.M. van; Rouhl, R.P.W.; Thomeer, E.C.; Moudrous, W.; Nijhuis, F.A.P.; Booij, S.J.; Hoedemaekers, C.W.E.; Doorduin, J.; Taccone, F.S.; Palen, J. van der; Putten, M.J.A.M. van; Hofmeijer, J.; TELSTAR Investigators
• Date: 2022-02-24
• Journal: New England Journal of Medicine
• Volume: 386
• Issue: 8
• Pages: 724 - 734
• DOI: doi:10.1056/NEJMoa2115998
• Link: https://www.nejm.org/doi/10.1056/NEJMoa2115998