Association of an electroencephalography-based risk score with seizure probability in hospitalized patients

Abstract

IMPORTANCE: Continuous electroencephalography (EEG) use in critically ill patients is expanding. There is no validated method to combine risk factors and guide clinicians in assessing seizure risk. OBJECTIVE: To use seizure risk factors from EEG and clinical history to create a simple scoring system associated with the probability of seizures in patients with acute illness. DESIGN, SETTING, AND PARTICIPANTS: We used a prospective multicenter (Emory University Hospital, Brigham and Women's Hospital, and Yale University Hospital) database containing clinical and electrographic variables on 5427 continuous EEG sessions from eligible patients if they had continuous EEG for clinical indications, excluding epilepsy monitoring unit admissions. We created a scoring system model to estimate seizure risk in acutely ill patients undergoing continuous EEG. The model was built using anew machine learning method (RiskSLIM) that is designed to produce accurate, risk-calibrated scoring systems with a limited number of variables and small integer weights. We validated the accuracy and risk calibration of our model using cross-validation and compared its performance with models built with state-of-the-art logistic regression methods. The database was developed by the Critical Care EEG Research Consortium and used data collected over3 years. The EEG variables were interpreted using standardized terminology by certified reviewers. EXPOSURES: All patients had more than 6 hours of uninterrupted EEG recordings. MAIN OUTCOMESAND MEASURES: The main outcome was the average risk calibration error. RESULTS: There were 5427 continuous EEGs performed on 4772 participants (2868 men, 49.9%; median age, 61 years) performed at 3 institutions, without further demographic stratification. Our final model, 2HELPS2B, had an area under the curve of 0.819 and average calibration error of 2.7% (95% CI, 2.0%-3.6%). It included 6 variables with the following point assignments: (1) brief (ictal) rhythmic discharges (B[I]RDs) (2 points); (2) presence of lateralized periodic discharges, lateralized rhythmic delta activity, or bilateral independent periodic discharges (1 point); (3) prior seizure (1 point); (4) sporadic epileptiform discharges (1 point); (5) frequency greater than 2.0 Hz for any periodic or rhythmic pattern (1 point); and (6) presence of "plus" features (superimposed, rhythmic, sharp, or fast activity) (1 point). The probable seizure risk of each score was 5% for a score of 0, 12% for a score of 1, 27% for a score of 2, 50% for a score of 3, 73% for a score of 4, 88% for a score of 5, and greater than 95% for a score of 6 or 7. CONCLUSIONS AND RELEVANCE: The 2HELPS2B model is a quick accurate tool to aid clinical judgment of the risk of seizures in critically ill patients.