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Background Neurologic injury is one of the most frequent causes of death in patients undergoing extracorporeal membrane oxygenation (ECMO). As neurological examination is often unreliable in sedated patients, additional neuromonitoring is needed. However, the value of electroencephalogram (EEG) in adult ECMO patients has not been well assessed. Therefore, the aim of this study was to assess the occurrence of electroencephalographic abnormalities in patients treated with extracorporeal membrane oxygenation (ECMO) and their association with 3-month neurologic outcome. Methods Retrospective analysis of all patients undergoing venous–venous (V–V) or venous–arterial (V–A) ECMO with a concomitant EEG recording (April 2009–December 2018), either recorded intermittently or continuously. EEG background was classified into four categories: mild/moderate encephalopathy (i.e., mostly defined by the presence of reactivity), severe encephalopathy (mostly defined by the absence of reactivity), burst-suppression (BS) and suppressed background. Epileptiform activity (i.e., ictal EEG pattern, sporadic epileptiform discharges or periodic discharges) and asymmetry were also reported. EEG findings were analyzed according to unfavorable neurological outcome (UO, defined as Glasgow Outcome Scale < 4) at 3 months after discharge. Results A total of 139 patients (54 [41–62] years; 60 (43%) male gender) out of 596 met the inclusion criteria and were analyzed. Veno–arterial (V–A) ECMO was used in 98 (71%); UO occurred in 99 (71%) patients. Continuous EEG was performed in 113 (81%) patients. The analysis of EEG background showed that 29 (21%) patients had severe encephalopathy, 4 (3%) had BS and 19 (14%) a suppressed background. In addition, 11 (8%) of patients had seizures or status epilepticus, 10 (7%) had generalized periodic discharges or lateralized periodic discharges, and 27 (19%) had asymmetry on EEG. In the multivariate analysis, the occurrence of ischemic stroke or intracranial hemorrhage (OR 4.57 [1.25–16.74]; p  = 0.02) and a suppressed background (OR 10.08 [1.24–82.20]; p  = 0.03) were independently associated with UO. After an adjustment for covariates, an increasing probability for UO was observed with more severe EEG background categories. Conclusions In adult patients treated with ECMO, EEG can identify patients with a high likelihood of poor outcome. In particular, suppressed background was independently associated with unfavorable neurological outcome.

Introduction Cortico‐cortical evoked potentials (CCEPs) were described as reproducible during trains of single‐pulse electrical stimulations (SPES). Still, few studies described a variability of CCEPs that was higher within the epileptogenic zone (EZ). This study aimed at characterizing the relationship of CCEP variability with the occurrence of interictal/ictal epileptiform discharges at the temporal vicinity of the stimulation, but not during the stimulation, by effective connectivity modifications. Methods We retrospectively included 20 patients who underwent SPES during their stereo‐electroencephalography (SEEG). We analyzed the variability of CCEPs by using the post‐stimulation time course of intertrial standard deviation (amplitude) and the timing of peak amplitude signal of CCEP epochs (latency). Values were corrected for the Euclidian distance between stimulating/recording electrodes. Receiver operating characteristics curves were used to assess the relationship with the EZ. The link between CCEP variability and interictal discharges occurrence, seizure frequency prior to the SEEG recording, and number of seizures during SEEG recording was assessed with Spearman's correlations. Results A relationship was demonstrated between the EZ and both the distance‐corrected latency variation (area under the curve (AUC): 0.73–0.74) and the distance‐corrected amplitude variation (AUC: 0.71–0.72) and both were related with the occurrence of seizures. Conclusion Seizures before/during SEEG impact the dynamics of effective connectivity within the epileptogenic network by reducing the variability of CCEP latency/amplitude when the seizure frequency increases. It suggests a strengthening of the epileptogenic network with the occurrence of many seizures. These findings stress the importance of early epilepsy surgery at a time when the network organization has not yet been complete.

Motivated by experiments on customers’ behavior in service systems, we consider a queueing model with event-dependent arrival rates. Customers’ arrival rates depend on the last event, which may either be a service departure or an arrival. We derive explicitly the performance measures and analyze the impact of the event-dependency. In particular, we show that this queueing model, in which a service completion generates a higher arrival rate than an arrival, performs better than a system in which customers are insensitive to the last event. Moreover, contrary to the M/G/1 queue, we show that the coefficient of variation of the service does not necessarily deteriorate the system performance. Next, we show that this queueing model may be the result of customers’ strategic behavior when only the last event is known. Finally, we investigate the historical admission control problem. We show that, under certain conditions, a deterministic policy with two thresholds may be optimal. This new policy is easy to implement and provides an improvement compared to the classical one-threshold policy.

ObjectiveThis prospective, bicentre, blinded, intention to treat study assessed the clinical added value of magnetic source imaging (MSI) in the presurgical evaluation of patients with refractory focal epilepsy (RFE).Methods70 consecutive patients with RFE (42 men; mean age 31.5 years, range 3–63) from two Belgian centres were prospectively included. All patients underwent conventional non-invasive presurgical evaluation (CNIPE) and a whole head magnetoencephalography recording (Elekta Neuromag). Equivalent current dipoles corresponding to interictal epileptiform discharges (IED) were fitted in the patients' spherical head model and coregistered on their MRI to produce MSI results. Results of CNIPE were first discussed blinded to the MSI results in respective multidisciplinary epilepsy surgery meetings to determine the presumed localisation of the epileptogenic zone and to set surgical or additional presurgical plans. MSI results were then discussed multidisciplinarily. MSI influence on the initial management plan was assessed.ResultsBased on CNIPE, 21 patients had presumed extratemporal epilepsy, 38 had presumed temporal epilepsy and 11 had undetermined localisation epilepsy. MSI showed IED in 52 patients (74.5%) and changed the initial management in 15 patients (21%). MSI related changes were significantly more frequent in patients with presumed extratemporal or undetermined localisation epilepsy compared with patients with presumed temporal epilepsy (p≤0.001). These changes had a clear impact on clinical management in 13% of all patients.ConclusionMSI is a clinically relevant, non-invasive neuroimaging technique for the presurgical evaluation of patients with refractory focal epilepsy and, particularly, in patients with presumed extratemporal and undetermined localisation epilepsy.

Introduction: The aims of this study were to assess the concordance of different tools and to describe the accuracy of a multimodal approach to predict unfavorable neurological outcome (UO) in cardiac arrest patients. Methods: Retrospective study of adult (>18 years) cardiac arrest patients who underwent multimodal monitoring; UO was defined as cerebral performance category 3–5 at 3 months. Predictors of UO were neurological pupillary index (NPi) ≤ 2 at 24 h; highly malignant patterns on EEG (HMp) within 48 h; bilateral absence of N20 waves on somato-sensory evoked potentials; and neuron-specific enolase (NSE) > 75 μg/L. Time-dependent decisional tree (i.e., NPi on day 1; HMp on day 1–2; absent N20 on day 2–3; highest NSE) and classification and regression tree (CART) analysis were used to assess the prediction of UO. Results: Of 137 patients, 104 (73%) had UO. Abnormal NPi, HMp on day 1 or 2, the bilateral absence of N20 or NSE >75 mcg/L had a specificity of 100% to predict UO. The presence of abnormal NPi was highly concordant with HMp and high NSE, and absence of N20 or high NSE with HMp. However, HMp had weak to moderate concordance with other predictors. The time-dependent decisional tree approach identified 73/103 patients (70%) with UO, showing a sensitivity of 71% and a specificity of 100%. Using the CART approach, HMp on EEG was the only variable significantly associated with UO. Conclusions: This study suggests that patients with UO had often at least two predictors of UO, except for HMp. A multimodal time-dependent approach may be helpful in the prediction of UO after CA. EEG should be included in all multimodal prognostic models.

To investigate epilepsy-induced changes in effective connectivity between the non-epileptic amygdalo-hippocampal complex (AHC) and the rest of the brain in patients with unilateral mesiotemporal lobe epilepsy (MTLE) associated with hippocampal sclerosis (HS). Thirty-three patients with unilateral MTLE associated with HS (20 females, mean age: 36 years, 19 left HS) and 33 adult controls matched for age and gender underwent (18)F-Fluorodeoxyglucose positron emission tomography (FDG-PET). Right-HS patients' FDG-PET data were flipped to obtain a left-epileptic-focus-lateralized group of patients. Voxels of interest (VOI) were selected within the cytoarchitectonic probabilistic maps of the non-epileptic AHC (probability level  = 100%, SPM8 Anatomy toolbox v1.7). Patients and controls were compared using VOI metabolic activity as covariate of interest to search for epilepsy-induced changes in the contribution of the non-epileptic AHC to the level of metabolic activity in other brain areas. Age, gender, duration of epilepsy, seizure type and frequency were used as covariates of no-interest for connectivity analyses. Significant decrease in effective connectivity was found between the non-epileptic AHC and ventral prefrontal cortical areas bilaterally, as well as with the temporal pole and the posterior cingulate cortex contralateral to HS. Significant increase in connectivity was found between the non-epileptic AHC and midline structures, such as the anterior cingulate and dorsal medial prefrontal cortices, as well as the temporo-parietal junction bilaterally. Connectivity analyses also revealed a preserved positive connectivity between the non-epileptic and the epileptic AHC in the patients' group. This study evidences epilepsy-induced changes in connectivity between the non-epileptic AHC and some limbic and default mode network areas. These changes in connectivity probably account for emotional, cognitive and decision-making impairments frequently observed in MTLE patients. The preserved neurometabolic connectivity between the non-epileptic and the epileptic AHC in MTLE patients is pivotal to explain the epilepsy-induced changes found in this study.

Status Epilepticus (SE) is a neurological emergency with high mortality rate that often requires admission in Intensive Care Units (ICU). Several factors of worse outcome have been identified in prior studies. The aim of our study was to determine the mortality in ICU and in the ward in patients with SE admitted to an ICU and to identify risk factors of mortality. Retrospective cohort study of patients admitted with SE treated in the ICU of a tertiary medical center between 2015 and 2020. The primary outcome measure was mortality in the ICU (ICU death) or in the ward after ICU discharge (post-ICU death). 252 patients were included, with a mean age of 63 (±16) years and 127 males (50 %). 58 died in the ICU, 27 died in the ward. Overall mortality was associated with a higher burden of comorbidities (OR:1.28, p < 0.001), the use of vasopressors (OR: 5.65, p < 0.001) and a higher burden of ICU complications (OR: 1.32, p = 0.002). Mortality rate was higher in more severe SE episodes (nonconvulsive, acute symptomatic and refractoriness. In-ICU mortality was associated with the use of vasopressors (OR: 7.92, p<0.001) and mechanical ventilation (OR: 3.13, p = 0.031), the length of in-ICU stay (OR: 0.91, p = 0.005) and a higher burden of ICU complications (OR: 1.37, p = 0.001). Compared to post-ICU deaths, ICU deaths also had higher Sequential Organ Failure Assessment (SOFA) score on ICU admission (p<0.001). Post-ICU mortality was associated with a higher burden of comorbidities (OR: 1.34, p<0.001), a higher burden of complications after ICU-discharge (OR: 1.33, p = 0.01), and more often refractory SE episode (OR: 2.63, p = 0.01). Compared to survivors, post-ICU deaths experienced mostly infectious and respiratory complications, after ICU-discharge. Death was more frequent in more severe SE episodes: non convulsive semiology, acute etiology, and refractoriness. In-ICU, post-ICU and all-cause mortality in patients with SE admitted to an ICU are all associated with a higher burden of comorbidities, which are non-modifiable prognostic factors, but also with a higher burden of complications, some of which are preventable, such as respiratory infections. •Status Epilepticus (SE) requiring ICU admission is high.•In-ICU mortality was associated with a more severe SE, a more severe medical condition and more complications during ICU stay.•Mortality after ICU discharge was associated with more comorbidities and complications after and during ICU stay.•Screening and prevention of complications could decrease mortality in SE.

Despite the many advantages of containerization for goods transportation, the management of empty containers is a major disadvantage, driving costly repositioning operations. We investigate the potential for consignees to manage an inventory of empty containers at their location so as to enable direct reuse of these containers by consignors located in the surroundings. One difficulty is that the detention fees imposed by shipping companies under merchant haulage are nonlinear. Moreover, cleaning and related activities might be necessary if the consignee keeps some empties. These difficulties incentivize consignees to immediately return containers to the sea terminal. Contrary to this practice, we show that managing containers via time‐based threshold policies can save costs. Without cleaning costs, we prove that a time‐based policy with a timeout return time is optimal. We next develop a policy improvement approach to include the cleaning costs in the analysis. This results in a two‐thresholds time‐based policy where the two time thresholds control the admission into and rejection out of the inventory. We next analyze the impact of this proactive management on the level of direct container reuse. This practice enables a high level of direct reuse. It also reduces container repositioning costs. Yet, the incentive to implement our policy varies a lot from one setting to another. In particular, low cleaning costs or high repositioning costs lead to significant costs improvement when implementing our policy. Finally, we further explore if the incentive could be made stronger by modifying the structure and/or purpose of the detention costs.

Background and purpose Depth electroencephalography (dEEG) is an emerging neuromonitoring technology in acute brain injury (ABI). We aimed to explore the concordances between electrophysiological activities on dEEG and on scalp EEG (scEEG) in ABI patients. Methods Consecutive ABI patients who received dEEG monitoring between 2018 and 2022 were included. Background, sporadic epileptiform discharges, rhythmic and periodic patterns (RPPs), electrographic seizures, brief potentially ictal rhythmic discharges, ictal–interictal continuum (IIC) patterns, and hourly RPP burden on dEEG and scEEG were compared. Results Sixty‐one ABI patients with a median dEEG monitoring duration of 114 h were included. dEEG significantly showed less continuous background (75% vs. 90%, p = 0.03), higher background amplitude (p < 0.001), more frequent rhythmic spike‐and‐waves (16% vs. 3%, p = 0.03), more IIC patterns (39% vs. 21%, p = 0.03), and greater hourly RPP burden (2430 vs. 1090 s/h, p = 0.01), when compared to scEEG. Among five patients with seizures on scEEG, one patient had concomitant seizures on dEEG, one had periodic discharges (not concomitant) on dEEG, and three had no RPPs on dEEG. Features and temporal occurrence of electrophysiological activities observed on dEEG and scEEG are not strongly associated. Patients with seizures and IIC patterns on dEEG seemed to have a higher rate of poor outcomes at discharge than patients without these patterns on dEEG (42% vs. 25%, p = 0.37). Conclusions dEEG can detect abnormal electrophysiological activities that may not be seen on scEEG and can be used as a complement in the neuromonitoring of ABI patients.

Background and purpose Post‐stroke epilepsy (PSE) is frequent. Better prediction of PSE would enable individualized management and improve trial design for epilepsy prevention. The aim was to assess the complementary value of continuous electroencephalography (EEG) data during the acute phase compared with clinical risk factors currently used to predict PSE. Methods A prospective cohort of 81 patients with ischaemic stroke who received early continuous EEG monitoring was studied to assess the association of early EEG seizures, other highly epileptogenic rhythmic and periodic patterns, and regional attenuation without delta (RAWOD, an EEG pattern of stroke severity) with PSE. Clinical risk factors were investigated using the SeLECT (stroke severity; large‐artery atherosclerosis; early clinical seizures; cortical involvement; territory of middle cerebral artery) scores. Results Twelve (15%) patients developed PSE. The presence of any of the investigated patterns was associated with a risk of epilepsy of 46%, with a sensitivity and specificity of 83% and 78%. The association remained significant after adjusting for the SeLECT score (odds ratio 18.8, interquartile range 3.8–72.7). Conclusions It was found that highly epileptogenic rhythmic and periodic patterns and RAWOD were associated with the development of PSE and complemented clinical risk factors. These findings indicate that continuous EEG provides useful information to determine patients at higher risk of developing PSE and could help individualize care.