Electrographic Seizures in the Critically Ill

A clinician's goal in treating a critically ill patient is to orchestrate a meaningful and fast recovery with minimal long-term sequelae, thereby improving their quality of life at best or preventing deterioration at worst. The path to achieving this goal becomes increasingly complex and foggy when seizures and IIC patterns are present. The first step is identifying patients at risk for seizures and determining the timing and duration of EEG monitoring. 2HELPS2B or other risk stratification schemes may help, but the ultimate goal should be overcoming the logistical and technical barriers that prevent near-uniform EEG monitoring during critical illness, much in the same way that elec-trocardiogram monitoring is currently used. Status epilepticus can cause secondary neurologic injury but the effects of discrete seizure burden and IIC patterns is still under investigation. The ambiguous nature of these EEG patterns necessitates ancillary testing where possible, such as NSE, neuroimaging with MRI, FDG-PET, or SPECT to better understand their malignant fea-tures. Treating status epilepticus, seizures, and IIC patterns is a delicate balance where the benefits and drawbacks of escalating IV anesthetic agents and ASM must be continually weighed. In addition to treating the EEG pattern, the clinician should focus on reversible causes such as metabolic disarray, offending drugs, infec-tion, or inflammation and surgically remediable causes such as subdural hemorrhage. The optimal order and combination of ASMs and IV anesthetics is still lacking, given the complex dynamic interplay of the forces in neurocritical care. Still, one can advo-cate for rational polypharmacy-that is, using antiseizure medications with different mechanisms of action and compatible pharmacokinetics. Weaning of ASMs in the acute and recovery stage of critical illness is also in need of further clarification. Answering these management questions will require an expanded use of multi-modal ancillary testing, multicenter collaboration with data harmonization and inno-vate trial designs for a data-driven approach to neurocritical care EEG with the goal of arresting neurologic deterioration and improving neurologic recovery.