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Performance of Spectrogram-Based Seizure Identification of Adult EEGs by Critical Care Nurses and Neurophysiologists

Amorim, Edilberto*,†; Williamson, Craig A.‡,§; Moura, Lidia M. V. R.*; Shafi, Mouhsin M.; Gaspard, Nicolas; Rosenthal, Eric S.*; Guanci, Mary M.#; Rajajee, Venkatakrishna‡,§; Westover, M. Brandon*

Journal of Clinical Neurophysiology: July 2017 - Volume 34 - Issue 4 - p 359–364
doi: 10.1097/WNP.0000000000000368
Original Research

Purpose: Continuous EEG screening using spectrograms or compressed spectral arrays (CSAs) by neurophysiologists has shorter review times with minimal loss of sensitivity for seizure detection when compared with visual analysis of raw EEG. Limited data are available on the performance characteristics of CSA-based seizure detection by neurocritical care nurses.

Methods: This is a prospective cross-sectional study that was conducted in two academic neurocritical care units and involved 33 neurointensive care unit nurses and four neurophysiologists.

Results: All nurses underwent a brief training session before testing. Forty two-hour CSA segments of continuous EEG were reviewed and rated for the presence of seizures. Two experienced clinical neurophysiologists masked to the CSA data performed conventional visual analysis of the raw EEG and served as the gold standard. The overall accuracy was 55.7% among nurses and 67.5% among neurophysiologists. Nurse seizure detection sensitivity was 73.8%, and the false-positive rate was 1-per-3.2 hours. Sensitivity and false-alarm rate for the neurophysiologists was 66.3% and 1-per-6.4 hours, respectively. Interrater agreement for seizure screening was fair for nurses (Gwet AC1 statistic: 43.4%) and neurophysiologists (AC1: 46.3%).

Conclusions: Training nurses to perform seizure screening utilizing continuous EEG CSA displays is feasible and associated with moderate sensitivity. Nurses and neurophysiologists had comparable sensitivities, but nurses had a higher false-positive rate. Further work is needed to improve sensitivity and reduce false-alarm rates.

Supplemental Digital Content is Available in the Text.

*Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.;

Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A.;

Departments of Neurosurgery and

§Neurology, University of Michigan, Ann Arbor, Michigan, U.S.A.;

Division of Epilepsy, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.;

Department of Neurology, Comprehensive Epilepsy Center, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium; and

#Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.

Address correspondence and reprint requests to M. Brandon Westover, MD, PhD, Department of Neurology, Massachusetts General Hospital, 15 Parkman St, Wang ACC 739 L, Boston, MA 02114, U.S.A.; e-mail:

M. B. Westover has received support from NIH-NINDS (1K23NS090900), the Andrew David Heitman Neuroendovascular Research Fund, and the Rappaport Foundation. The remaining authors have no funding or conflicts of interest to disclose.

Presented at the 13th Annual Neurocritical Care Society Meeting, Scottsdale, Arizona, October 7-9, 2015.

E. Amorim and C. A. Williamson contributed equally to this work.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

© 2017 by the American Clinical Neurophysiology Society