Résumé
Les explorations neurophysiologiques complètent l’évaluation clinique et radiologique d’un enfant cérébrolésé. Leur intérêt est à la fois diagnostique, quand il s’agit de mettre en évidence des crises convulsives ou une mort encéphalique pour l’électroencéphalogramme (EEG) ou d’évaluer une dysfonction du tronc cérébral pour les potentiels évoqués (PE) auditifs précoces, et pronostique pour prédire un mauvais devenir neurologique dans les comas anoxiques. À la phase aiguë d’un traumatisme crânien grave (TCG) et d’une méningite, il est utile de reconnaître et de traiter des convulsions ; néanmoins, la fréquence des états épileptiques non convulsifs est importante et variable selon les études (de 7 à 48 %). Bien que lourdes et coûteuses, les techniques d’EEG continues pourraient en améliorer la détection. D’où le développement de techniques d’EEG d’amplitude, dont l’intérêt reste encore à préciser en pédiatrie. Concernant le pronostic, certains tracés EEG comme des burst-suppression, un tracé nul ou un état de mal convulsif sont considérés comme mauvais. La valeur prédictive des EEG reste limitée et inférieure à celle des PE somesthésiques (PES). Les PES ont une excellente valeur prédictive dans les comas anoxiques de l’adulte et de l’enfant (de 94 à 100 %, selon les études), surtout en combinaison avec l’évaluation des réflexes pupillaires et des réponses motrices après 48 heures. En revanche, la prédiction d’un devenir neurologique favorable est moins performante. Pour les TCG et les méningites, la performance des PES est moins bonne. L’étude des PE cognitifs ou négativité de discordance (MMN) pourrait améliorer la prédiction du réveil.
Abstract
Neurophysiological tests complete clinical and radiological assessments in brain-injured children. Electroencephalogram (EEG) is clearly helpful to diagnose seizures and brain death while auditory evoked potentials (EP) to assess brainstem dysfunction and predict poor neurological outcome in post-anoxic coma. During the acute phase of severe traumatic brain injury (TBI) and bacterial meningitis, early recognition and treatment of convulsive seizures is essential. The incidence of non-convulsive seizures remains, however, high, varying between 7 and 48%. Although costly and time consuming, continuous EEG monitoring techniques may allow improving seizure detection. Therefore, amplitude integrated EEG techniques have been developed; however, they still require assessment in paediatrics. Some EEG patterns are indicative of a final bad outcome, including burst suppression, isoelectric pattern, and status epilepticus. EEG predictive value remains limited and less useful than somatosensory EP (SEP). SEP have excellent predictive value in post-anoxic coma in adults as well as in children (94 to 100%), especially in combination to pupillary reflexes and motor responses assessed after 48 h. In contrast, their predictive value of a good outcome is less reliable. In severe TBI and bacterial meningitis, this performance is also limited. Investigation of cognitive EP or mismatch negativity (MMN) could improve awakening prediction.
Article PDF
Avoid common mistakes on your manuscript.
Références
Guerit JM, Amantini A, Amodio P, et al (2009) Consensus on the use of neurophysiological tests in the intensive care unit (ICU): electroencephalogram (EEG), evoked potentials (EP), and electroneuromyography (ENMG). Neurophysiol Clin 39:71–78
Wong CP, Forsyth RJ, Kelly TP, Eyre JA (2001) Incidence, aetiology, and outcome of non-traumatic coma: a population based study. Arch Dis Child 84:193–199
Tasker RC, Boyd S, Harden A, Matthew DJ (1988) Monitoring in non-traumatic coma. Part II: Electroencephalography. Arch Dis Child 63:895–899
Zandbergen EG, de Haan RJ, Stoutenbeek CP, et al (1998) Systematic review of early prediction of poor outcome in anoxicischaemic coma. Lancet 352:1808–1812
Abend NS, Licht DJ (2008) Predicting outcome in children with hypoxic ischemic encephalopathy. Pediatr Crit Care Med 9:32–39
Trubel HK, Novotny E, Lister G (2003) Outcome of coma in children. Curr Opin Pediatr 15:283–287
Mandel R, Martinot A, Delepoulle F, et al (2002) Prediction of outcome after hypoxic-ischemic encephalopathy: a prospective clinical and electrophysiologic study. J Pediatr 141:45–50
Ruiz-Garcia M, Gonzalez-Astiazaran A, Collado-Corona MA, et al (2000) Brain death in children: clinical, neurophysiological and radioisotopic angiography findings in 125 patients. Childs Nerv Syst 16:40–45
Boulard G, Guiot P, Pottecher T, Tenaillon A (2005) Prise en charge des sujets en état de mort encéphalique dans l’optique d’un prélèvement d’organe. Conférence d’experts SRLF, SFAR, Agence de Biomédecine. Elsevier, Paris
Shahwan A, Bailey C, Shekerdemian L, Harvey AS (2010) The prevalence of seizures in comatose children in the pediatric intensive care unit: a prospective video-EEG study. Epilepsia 51:1198–1204
Abend NS, Topjian AA, Gutierrez-Colina AM, et al (2011) Impact of continuous EEG monitoring on clinical management in critically ill children. Neurocrit Care 15:70–75
Claassen J, Mayer SA, Kowalski RG, et al (2004) Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 62:1743–1748
McCoy B, Sharma R, Ochi A, et al (2011) Predictors of nonconvulsive seizures among critically ill children. Epilepsia 52:1973–1978
Liesemer K, Bratton SL, Zebrack CM, et al (2011) Early posttraumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. J Neurotrauma 28:755–762
Barlow KM, Spowart JJ, Minns RA (2000) Early posttraumatic seizures in non-accidental head injury: relation to outcome. Dev Med Child Neurol 42:591–594
Stewart CP, Otsubo H, Ochi A, et al (2010) Seizure identification in the ICU using quantitative EEG displays. Neurology 75:1501–1508
Carrai R, Grippo A, Lori S, et al (2010) Prognostic value of somatosensory evoked potentials in comatose children: a systematic literature review. Intensive Care Med 36:1112–1126
Beca J, Cox PN, Taylor MJ, et al (1995) Somatosensory evoked potentials for prediction of outcome in acute severe brain injury. J Pediatr 126:44–49
Carter BG, Butt W (2005) A prospective study of outcome predictors after severe brain injury in children. Intensive Care Med 31:840–845
De Meirleir LJ, Taylor MJ (1987) Prognostic utility of SEPs in comatose children. Pediatr Neurol 3:78–82
Pohlmann-Eden B, Dingethal K, Bender HJ, Koelfen W (1997) How reliable is the predictive value of SEP (somatosensory evoked potentials) patterns in severe brain damage with special regard to the bilateral loss of cortical responses? Intensive Care Med 23:301–308
Wohlrab G, Boltshauser E, Schmitt B (2001) Neurological outcome in comatose children with bilateral loss of cortical somatosensory evoked potentials. Neuropediatrics 32:271–274
Lutschg J, Pfenninger J, Ludin HP, Vassella F (1983) Brain-stem auditory evoked potentials and early somatosensory evoked potentials in neurointensively treated comatose children. Am J Dis Child 137:421–426
Fischer C, Morlet D, Bouchet P, et al (1999) Mismatch negativity and late auditory evoked potentials in comatose patients. Clin Neurophysiol 110:1601–1610
Fischer C, Luaute J, Adeleine P, Morlet D (2004) Predictive value of sensory and cognitive evoked potentials for awakening from coma. Neurology 63:669–673
Fischer C, Luaute J, Nemoz C, et al (2006) Improved prediction of awakening or nonawakening from severe anoxic coma using tree-based classification analysis. Crit Care Med 34:1520–1524
Gomot M, Giard MH, Roux S, et al (2000) Maturation of frontal and temporal components of mismatch negativity (MMN) in children. Neuroreport 11:3109–3112
Jing H, Benasich AA (2006) Brain responses to tonal changes in the first two years of life. Brain Dev 28:247–256
Author information
Authors and Affiliations
Corresponding author
Additional information
Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2012 dans la session : Surveillance paraclinique de l’enfant cérébrolésé.
Rights and permissions
About this article
Cite this article
Javouhey, E., Manel, V. & André-Obadia, N. Les explorations neurophysiologiques chez l’enfant cérébrolésé : quand, comment ?. Réanimation 21 (Suppl 2), 347–353 (2012). https://doi.org/10.1007/s13546-011-0429-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13546-011-0429-6