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a colour display that represents the frequencies and amplitudes of brain waves through time&#44; with the colour spectrum ranging from blue &#40;minimum amplitude&#41; to dark red &#40;maximum amplitude&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of two patients in which the use of the DSA was useful in the detection and monitoring of SE&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">Boy aged 5 months admitted for head trauma&#46; At admission&#44; he had a partial seizure with clonic movements in the left leg that did not respond to antiepileptic treatment and progressed to a secondary generalised tonic-clonic SE&#46; The patient was intubated and an EEG requested that showed focal epileptiform discharges in the right frontal region and slow waves in the left temporo-occipital region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The epileptiform activity disappeared with administration of midazolam&#44; and we placed a bilateral BIS sensor to adjust the depth of anaesthesia&#46; At 40<span class="elsevierStyleHsp" style=""></span>min the DSA showed an abrupt change&#44; shifting from orange&#44; yellow and green colours in the low-frequency bands to dark red tones &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; with no clinical evidence of ictus&#46; The BIS electroencephalographic signal showed epileptiform discharges similar to those seen in conventional EEG&#44; which were interpreted as recurrent epileptic activity&#46; Since continuous video-EEG monitoring &#40;cEEG&#41; was not available&#44; we administered thiopental&#44; after which the discharges no longer appeared in the display and green and yellow tones reappeared in the DSA&#46; The following day&#44; a new EEG confirmed the absence of epileptiform activity&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">Girl aged 7 years admitted for suspected meningoencephalitis&#46; She had a partial seizure with clonic movements in the left shoulder that did not respond to antiepileptic treatment and progressed to a secondary generalised tonic-clonic SE&#46; The patient was intubated and given midazolam intravenously&#44; which achieved control of the clonic movements&#46; However&#44; the EEG showed continuous bilateral asymmetrical epileptiform discharges of spike-and-wave complexes with maximum amplitudes in the right temporo-occipital and temporal regions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; We administered thiopental intravenously and placed a bilateral BIS sensor to titrate the barbiturate sedation&#46; At first&#44; we observed epileptiform discharges in the BIS EEG channels associated to a spike pattern with predominance of dark red tones in the DSA&#44; which gradually changed to blue colours with a BIS value of 10 that served as the therapeutic target for maintaining a burst-suppression pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; At 48<span class="elsevierStyleHsp" style=""></span>h&#44; a new conventional EEG confirmed the absence of seizures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In cases of convulsive SE&#44; the disappearance of clinical seizures does not always correspond to control of the SE&#44; and persisting epileptic discharges have been described in up to 48&#37; of patients without motor manifestations &#40;nonconvulsive SE&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> For this reason&#44; cEEG monitoring is recommended to verify the effectiveness of treatment&#44; although it is not widely available in Spanish PICUs yet&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; the complexity of the interpretation of cEEG monitoring tracings has led to the development of algorithms based on the quantitative analysis of the signal&#44; such as amplitude-integrated EEG or colour DSA&#44; with the purpose of simplifying the review of long-term EEG data&#46; In this regard&#44; Pensirikul et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> evaluated DSA in the detection of epileptic seizures in 21 critical children&#44; and obtained favourable results&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our group has previously described the use of the bilateral BIS DSA in adults with SE&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> finding that the presence of dark red tones in the low-frequency bands is suggestive of SE&#46; However&#44; variations in the amplitude&#44; frequency and rhythm of epileptiform discharges in each patient require the comparison of the SDA with the findings of a conventional EEG interpreted by an expert neurophysiologist in order to establish the patterns displayed by the DSA during seizures and periods of seizure control&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Keeping in mind the limitations of BIS monitoring in relation to muscle artefacts and the scarcity of parieto-occipital region data&#44; the described cases show that the bilateral BIS monitoring DSA could be used as a supplementary tool for monitoring SE&#44; especially in facilities where cEEG monitoring is not available&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Hern&#225;ndez-Hern&#225;ndez MA&#44; Iglesias-Posadilla D&#44; Ruiz-Ruiz A&#44; G&#243;mez-Marcos V&#44; Fern&#225;ndez-Torre JL&#46; Matriz de densidad espectral de color del BIS bilateral en estado epil&#233;ptico&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;85&#58;44&#8211;47&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1 &#40;A&#41; EEG showing frequent focal epileptiform discharges involving the entire right frontal lobe &#40;Fp2&#44; F4&#44; F8&#41; and increased slow waves in the left temporo-occipital region&#59; low-frequency filter&#58; 0&#46;53<span class="elsevierStyleHsp" style=""></span>Hz&#59; high-frequency filter&#58; 30<span class="elsevierStyleHsp" style=""></span>Hz&#59; notch filter&#58; 50<span class="elsevierStyleHsp" style=""></span>Hz&#46; Vertical bar&#58; 100<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; horizontal bar&#58; 1<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;B&#41; DSA showing an abrupt change in colour &#40;long arrow&#41; from orange&#44; yellow and green tones to dark red tones in the low-frequency band &#40;&#60;10<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#44; suggestive of recurrent epileptic activity&#46; After a little over one hour&#44; the DSA returned to its previous features concurrently with the administration of thiopental &#40;short arrow&#41;&#46; The white line in the DSA represents the spectral edge frequency &#40;SEF&#41;&#44; which is the frequency in Hertz below which 95&#37; of the power of the brain resides&#46; &#40;In the black and white printout&#44; the dark red in the low-frequency band appears as dark grey tones that are nearly black&#46;&#41;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 2 &#40;A&#41; EEG with evidence of bilateral epileptiform discharges with spike-and-wave complexes between 2 and 3<span class="elsevierStyleHsp" style=""></span>Hz and up to 300<span class="elsevierStyleHsp" style=""></span>&#956;V in amplitude&#44; with maximum amplitude in the temporal lobe and parieto-occipital regions of the right hemisphere &#40;F8&#44; T4&#44; T6&#44; O2&#41;&#46; Low-frequency filter&#58; 0&#46;53<span class="elsevierStyleHsp" style=""></span>Hz&#59; high-frequency filter&#58; 30<span class="elsevierStyleHsp" style=""></span>Hz&#59; notch filter&#58; 50<span class="elsevierStyleHsp" style=""></span>Hz&#46; Vertical bar&#58; 200<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; horizontal bar&#58; 1<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;B&#41; DSA initially characterised by a dark red spike pattern with predominance of the right hemisphere due to the high amplitude of the epileptic discharges on this side&#46; Following initiation of IV thiopental&#44; the DSA shows a progressive change until blue tones become predominant&#44; which indicates a drop in brain wave amplitude consistent with a burst-suppression pattern&#46; &#40;In the black and white printout&#44; the dark red in the low-frequency band appears as dark grey tones that are nearly black&#46; Following initiation of thiopental&#44; these tones lighten progressively under the white line &#91;SEF&#93; until they disappear&#46;&#41;</p>"
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Scientific Letter
Colour density spectral array of bilateral bispectral index in status epilepticus
Matriz de densidad espectral de color del BIS bilateral en estado epiléptico
Miguel Ángel Hernández-Hernándeza,c,
Corresponding author
mahernandez@humv.es

Corresponding author.
, David Iglesias-Posadillaa, Ana Ruiz-Ruiza,c, Vanesa Gómez-Marcosa, José Luis Fernández-Torreb,c,d
a Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
b Servicio de Neurofisiología Clínica, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
c Instituto de Investigación Valdecilla (IDIVAL), Santander, Cantabria, Spain
d Departamento de Fisiología y Farmacología, Facultad de Medicina, Universidad de Cantabria (UNICAN), Santander, Cantabria, Spain
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a colour display that represents the frequencies and amplitudes of brain waves through time&#44; with the colour spectrum ranging from blue &#40;minimum amplitude&#41; to dark red &#40;maximum amplitude&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of two patients in which the use of the DSA was useful in the detection and monitoring of SE&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">Boy aged 5 months admitted for head trauma&#46; At admission&#44; he had a partial seizure with clonic movements in the left leg that did not respond to antiepileptic treatment and progressed to a secondary generalised tonic-clonic SE&#46; The patient was intubated and an EEG requested that showed focal epileptiform discharges in the right frontal region and slow waves in the left temporo-occipital region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The epileptiform activity disappeared with administration of midazolam&#44; and we placed a bilateral BIS sensor to adjust the depth of anaesthesia&#46; At 40<span class="elsevierStyleHsp" style=""></span>min the DSA showed an abrupt change&#44; shifting from orange&#44; yellow and green colours in the low-frequency bands to dark red tones &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; with no clinical evidence of ictus&#46; The BIS electroencephalographic signal showed epileptiform discharges similar to those seen in conventional EEG&#44; which were interpreted as recurrent epileptic activity&#46; Since continuous video-EEG monitoring &#40;cEEG&#41; was not available&#44; we administered thiopental&#44; after which the discharges no longer appeared in the display and green and yellow tones reappeared in the DSA&#46; The following day&#44; a new EEG confirmed the absence of epileptiform activity&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">Girl aged 7 years admitted for suspected meningoencephalitis&#46; She had a partial seizure with clonic movements in the left shoulder that did not respond to antiepileptic treatment and progressed to a secondary generalised tonic-clonic SE&#46; The patient was intubated and given midazolam intravenously&#44; which achieved control of the clonic movements&#46; However&#44; the EEG showed continuous bilateral asymmetrical epileptiform discharges of spike-and-wave complexes with maximum amplitudes in the right temporo-occipital and temporal regions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; We administered thiopental intravenously and placed a bilateral BIS sensor to titrate the barbiturate sedation&#46; At first&#44; we observed epileptiform discharges in the BIS EEG channels associated to a spike pattern with predominance of dark red tones in the DSA&#44; which gradually changed to blue colours with a BIS value of 10 that served as the therapeutic target for maintaining a burst-suppression pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; At 48<span class="elsevierStyleHsp" style=""></span>h&#44; a new conventional EEG confirmed the absence of seizures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In cases of convulsive SE&#44; the disappearance of clinical seizures does not always correspond to control of the SE&#44; and persisting epileptic discharges have been described in up to 48&#37; of patients without motor manifestations &#40;nonconvulsive SE&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> For this reason&#44; cEEG monitoring is recommended to verify the effectiveness of treatment&#44; although it is not widely available in Spanish PICUs yet&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; the complexity of the interpretation of cEEG monitoring tracings has led to the development of algorithms based on the quantitative analysis of the signal&#44; such as amplitude-integrated EEG or colour DSA&#44; with the purpose of simplifying the review of long-term EEG data&#46; In this regard&#44; Pensirikul et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> evaluated DSA in the detection of epileptic seizures in 21 critical children&#44; and obtained favourable results&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our group has previously described the use of the bilateral BIS DSA in adults with SE&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> finding that the presence of dark red tones in the low-frequency bands is suggestive of SE&#46; However&#44; variations in the amplitude&#44; frequency and rhythm of epileptiform discharges in each patient require the comparison of the SDA with the findings of a conventional EEG interpreted by an expert neurophysiologist in order to establish the patterns displayed by the DSA during seizures and periods of seizure control&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Keeping in mind the limitations of BIS monitoring in relation to muscle artefacts and the scarcity of parieto-occipital region data&#44; the described cases show that the bilateral BIS monitoring DSA could be used as a supplementary tool for monitoring SE&#44; especially in facilities where cEEG monitoring is not available&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Hern&#225;ndez-Hern&#225;ndez MA&#44; Iglesias-Posadilla D&#44; Ruiz-Ruiz A&#44; G&#243;mez-Marcos V&#44; Fern&#225;ndez-Torre JL&#46; Matriz de densidad espectral de color del BIS bilateral en estado epil&#233;ptico&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;85&#58;44&#8211;47&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1 &#40;A&#41; EEG showing frequent focal epileptiform discharges involving the entire right frontal lobe &#40;Fp2&#44; F4&#44; F8&#41; and increased slow waves in the left temporo-occipital region&#59; low-frequency filter&#58; 0&#46;53<span class="elsevierStyleHsp" style=""></span>Hz&#59; high-frequency filter&#58; 30<span class="elsevierStyleHsp" style=""></span>Hz&#59; notch filter&#58; 50<span class="elsevierStyleHsp" style=""></span>Hz&#46; Vertical bar&#58; 100<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; horizontal bar&#58; 1<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;B&#41; DSA showing an abrupt change in colour &#40;long arrow&#41; from orange&#44; yellow and green tones to dark red tones in the low-frequency band &#40;&#60;10<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#44; suggestive of recurrent epileptic activity&#46; After a little over one hour&#44; the DSA returned to its previous features concurrently with the administration of thiopental &#40;short arrow&#41;&#46; The white line in the DSA represents the spectral edge frequency &#40;SEF&#41;&#44; which is the frequency in Hertz below which 95&#37; of the power of the brain resides&#46; &#40;In the black and white printout&#44; the dark red in the low-frequency band appears as dark grey tones that are nearly black&#46;&#41;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 2 &#40;A&#41; EEG with evidence of bilateral epileptiform discharges with spike-and-wave complexes between 2 and 3<span class="elsevierStyleHsp" style=""></span>Hz and up to 300<span class="elsevierStyleHsp" style=""></span>&#956;V in amplitude&#44; with maximum amplitude in the temporal lobe and parieto-occipital regions of the right hemisphere &#40;F8&#44; T4&#44; T6&#44; O2&#41;&#46; Low-frequency filter&#58; 0&#46;53<span class="elsevierStyleHsp" style=""></span>Hz&#59; high-frequency filter&#58; 30<span class="elsevierStyleHsp" style=""></span>Hz&#59; notch filter&#58; 50<span class="elsevierStyleHsp" style=""></span>Hz&#46; Vertical bar&#58; 200<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; horizontal bar&#58; 1<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;B&#41; DSA initially characterised by a dark red spike pattern with predominance of the right hemisphere due to the high amplitude of the epileptic discharges on this side&#46; Following initiation of IV thiopental&#44; the DSA shows a progressive change until blue tones become predominant&#44; which indicates a drop in brain wave amplitude consistent with a burst-suppression pattern&#46; &#40;In the black and white printout&#44; the dark red in the low-frequency band appears as dark grey tones that are nearly black&#46; Following initiation of thiopental&#44; these tones lighten progressively under the white line &#91;SEF&#93; until they disappear&#46;&#41;</p>"
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