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Burst Suppression: A More Valid Marker of Postictal Central Inhibition?

Kranaster, Laura MD*; Plum, Peter MD; Hoyer, Carolin MD*; Sartorius, Alexander MD, PhD*; Ullrich, Heiko MD

doi: 10.1097/YCT.0b013e3182622c0e
Original Studies

Objectives A valid marker to predict seizure adequacy in electroconvulsive therapy (ECT) is still missing. Postictal suppression has been claimed to correlate with the antidepressive effectiveness of an induced seizure. Postictal suppression index (PSI) is derived from a short time span of electroencephalographic recording at seizure termination, and, alternatively, burst suppression (BS) index is defined as the percentage of suppressed epochs within a predefined time period.

Methods In a retrospective study including 9 patients with a total of 104 recorded ECT sessions, we compared the influence of variables that are known to alter seizure adequacy like age, stimulation dose, electrode position, and the number of the consecutive ECT sessions on both indices, PSI versus BS index.

Results For PSI, electrode positioning turned out to be a significant independent variable, with bilateral placement revealing higher PSI. Electroconvulsive therapy session number was significant for BS index, with lower burst suppression in higher ECT session number. In contrast to PSI, BS index turned out to be a significant covariate of seizure duration. Postictal suppression index and BS index did not show linear but a significant rank correlation.

Conclusions We report first data about postictal BS index in ECT. As a measure of postictal electrical suppression, BS index appears as robust as PSI. Burst suppression index decreases during an individual ECT course, which presumably reflects the anticonvulsive effect of ECT. Less artifact-prone methods of automatic quantification of electrical suppression could improve precise determination of individual seizure adequacy.

From the *Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany and †Department of Psychiatry and Psychotherapy, Kreisklinikum Siegen GmbH, Siegen, Germany.

Received for publication March 8, 2012; accepted May 24, 2012.

Reprints: Alexander Sartorius, MD, PhD, Department of Psychiatry and Psychotherapy Central Institute of Mental Health (CIMH) Medical Faculty Mannheim, University of Heidelberg J5, 68159 Mannheim, Germany (e-mail:

The authors have no conflicts of interest or financial disclosures to report.

© 2013 Lippincott Williams & Wilkins, Inc.