AAN 2025 | The 2HELPS2B score: stratifying the risk of electrographic seizures in patients in the ICU

The 2HELPS2B score was created and later validated by Dr Aaron Strach, a colleague and friend of mine. It’s a great way to stratify the risk of the patient having electrographic seizures when they’re on continuous EEG monitoring. So the 2HELPS2B score, it has one clinical variable and the rest are electrography variables. So you put a patient on EEG and within one hour you have enough information to get the risk of the patient of having seizures in the next hours or days. You can have a risk of zero which means that within one hour to two hours you’re good to go and you can discontinue the EEG because the risk of the patient having a seizure in the next days is less than 5%. You can have a score of 1, so you will have to continue with EEG for at least 12 hours to reach the risk of having an electrographic seizure less than 5%. And you have a risk, you have a score of two or more, you have to continue on EEG for at least 24 hours in order to achieve a risk of having seizure less than 5%. If you want to reach to a risk of less than 2%, then you will have to continue with a little more prolonged time of EEG that is very well described in the paper of RNS drug. Generally, in our institution we use the less than 5%. And why is this score so valuable? Because as we know, over the last two decades, continuous EEG has tremendously increased its use in the hospitals, especially in high-income countries, because of recognition of electrographic seizures being a commonality of a complication in patients that are critically ill and not only with brain injuries, it also has been seen in the medical ICU and the surgical ICU. And with this increase of continuous EEG use, our former guidelines and the last guidelines that we have in 2016 of the utility and indication for continuous EEG in critically ill patients recommends a monitoring of 24 to 48 hours for the detection of electrographic seizures. This recommendation is based on studies that have been done years ago when they analyzed and looked at all the patients that were on continuous EEG and saw the incidence of when the electrographic seizures were diagnosed. They found that within 24 hours you reach about 92 percent, an extra day you get 95 percent, and an extra that you get almost 98 percent. So based on that study the recommendation is 24 to 48 hours but after the recommendations the demand of continuous EEG has exploded which is wonderful it is great because we want to make sure that we are treating our patients in a very a global way. But it had exploded so much that the demand overwhelms the offer. We have a certain amount of machines, we have a certain amount of EEG technicians, we have a certain amount of human capacity for the EEG reader to review the EEGs on a daily basis. So when the 2HELPS2B score was established in 2017 and validated in 2019, and seeing in our own institutions in UNC, how with the presence of ICU EEGers in UNC, how the exponential of demand grew within UNC, we discussed about implementing clinically the 2HELPS2B score to help us stratify which patients were in medium to high risk, meaning more than one point, and for what they needed, the continuous EEG prolonged for 12 to 24 hours, as the guidelines has recommended. But importantly we can also stratify the patients that were a zero point that they didn’t need a prolonged EEG monitoring for what we can actually take the machine off and use it in a different patient. So we started implementing this 2HELPS2B score about two to three years ago. We started first clinically, there was a joint effort between the epilepsy team and the neurocritical care team at UNC, which we met together and discussed about the implementation of the score in our reports. But before it went to our reports, we actually just implemented verbally, which at one time during the day, the neuroICU attending and the epilepsy attending that was on EEG monitoring read for that week, got together and discussed all the ICU EEGs for the neurocritical care team. And we relate the score that the patient had at that moment within two hours of continuous EEG monitoring. We did it at two hours. We only implemented this touch-based daily point during working hours because at night, you know, we read until 10 p.m. and then overnight, it’s our residents, our fellows, our technicians that do the monitoring and there’s any emergency they will call us. But we don’t routinely check in the middle of the night in these patients. So by implementing the score at UNC we were able to reduce the amount of continuous EEG in the patients that were at low risk for what it allowed us to use that machine for other patients without really compromising the seizures detection. Of course, we want to make sure that we don’t compromise patient care. So we analyzed into the incidence of electrographic seizures before implementations and after implementation, and it was the same. It was not significantly different. However, what was significantly different was that we reduced the amount of continuous EEG hours in patients that were at low risk, which is the risk of zero. And for risk one and two and above, the monitoring was not changed at all. With this implementation, it’s wise to apply it in other centers so we can have a better resource utilization of our machines and our medical personnel. And especially, for example, in centers that they don’t have enough machines, so they don’t have a lot of machines. You know, I’ve been working with lower to middle income countries, primarily with Latin America. and in Mexico City this score is already been implemented by Dr Elma Paredes after we have discussed our experience and she has implemented at her center in the biggest neuroscience institute of Mexico City and she will do an analysis of the results in the future but nowadays she has only one machine and what she does is the same with the one machine that she has monitor the patients and then stratify by the 2HELPS2B score risk, and continue with EEG in the patients or stop the monitoring so you can have the machine for the next patient to come. Before that, she was obligated that she has to continue with EEG monitoring as per the guidelines until the 16th, say 24 to 48 hours. But honestly, if it’s a zero points, there’s no need to continue because your risk of having a seizure is less than 5%, so you have a better wisely use of resource utilization of that machine for a next patient to come. And similar to Dr Paredes in Mexico, it’s something that we can actually implement within our country, in the United States, because UNC, as other institutions, have a lot of resources, but in rural hospitals, they don’t have all the resources that we do. So if they have one or two machines, they can also possibly implement this type of risk stratification score and they can provide more monitoring for more patients by reducing the necessary monitoring in patients that are at low risk.

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