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Is there clinical benefit from early electroencephalography monitoring in very preterm infants?

Numerous studies have documented the high prevalence of developmental impairment in very preterm (VPT) infants (<32 weeks gestation) (1). Magnetic resonance imaging (MRI) at term and later in life has shown a high prevalence of acquired brain injury of various types in these infants (2,3). With the exception of intraventricular haemorrhage (IVH), there is scant evidence on timing and treatment of such brain injuries. The study by Wikström et al. (4) in this edition of Acta Paediatrica sheds new light on this timing and may improve selection of infants for brain-oriented treatments. While neuroimaging tells us about what has happened to the brain in the past, electroencephalography (EEG) is telling us how the brain is functioning as it happens now. Thus, one might expect that EEG would give earlier indication of brain injury than cranial ultrasound or MRI. In recent years, continuous EEG has been combined with amplitude-integrated EEG in commercially available equipment that even a stressed neonatologist or a busy nurse can apply in the middle of the night while other intensive care procedures are going on. The CoolCap (5), TOBY (6) and neo.nEuro trials (7) of therapeutic hypothermia used aEEG ⁄ EEG as inclusion criteria, and this experience showed many neonatologists that aEEG ⁄ EEG is predictive of outcome in term infants treated with hypothermia for hypoxic-ischaemic encephalopathy (8) and has the advantage over clinical neurological assessment that the permanent record can be re-examined objectively by experts at a later time. A number of training courses in many countries have disseminated these techniques to medical and nursing staff (9). While needle electrodes are generally preferred in term infants with encephalopathy, skin electrodes are preferred in VPT infants because of the fragile skin, lack of hair and high risk of infection. Wikström et al. (4) showed that a low voltage or burst suppression EEG in the first 24 h of VPT infants was highly predictive of poor developmental outcome. The VPT EEG is characterized by relatively flat (suppressed) periods alternating with high-voltage bursts. The longer the flat interburst intervals, the more impaired is brain function at the time. Depending on whether median interburst interval was over or under 6 sec, at 24 h, developmental outcome was correctly predicted in 74%. If the EEG was suppressed for more (or less) than 55% of a 1 h recording, this correctly predicted developmental outcome in 79%. Measuring interburst interval can be performed by inspection over short periods of time but to do it over 1 h means examining 108 m of EEG recording which neonatal clinicians would not have the time to do. Wikström et al. (10) have developed software that can automatically calculate interburst interval, and this opens up the possibility of clinical monitoring. Continuous EEG and aEEG are already used by some neonatologists to detect electrical seizures and it has been recognized that very short seizures less than a minute may not be detected by aEEG. Wikström et al. (4) found 89 electrical seizures in 21 of the infants (43%) but the median duration was 60 sec. Seizure occurrence or duration did not correlate statistically with outcome but status Invited Commentary for Wikström et al. Early single-channel aEEG/EEG predicts outcome in very preterm infants, pages 719– 726. Acta Pædiatrica ISSN 0803–5253