# Real-time segmentation and tracking of brain metabolic state in ICU EEG recordings of burst suppression

**Abstract**

We provide a method for estimating brain metabolic state based on a reduced-order model of EEG burst suppression. The model, derived from previously suggested biophysical mechanisms of burst suppression, describes important electrophysiological features and provides a direct link to cerebral metabolic rate. We design and fit the estimation method from EEG recordings of burst suppression from a neurological intensive care unit and test it on real and synthetic data.

Real-Time Segmentation and Tracking of Brain Metabolic State in ICU

EEG Recordings of Burst Suppression

M. Brandon Westover

7

, ShiNung Ching

1,3,4

, Mouhsin M. Shaﬁ

7

, Sydney S. Cash

7

and Emery N. Brown

1,4,5,6

Abstract— We provide a method for estimating brain

metabolic state based on a reduced-order model of EEG burst

suppression. The model, derived from previously suggested

biophysical mechanisms of burst suppression, describes impor-

tant electrophysiological features and provides a direct link

to cerebral metabolic rate. We design and ﬁt the estimation

method f rom EEG recordings of burst suppression from a

neurological intensive care unit and test it on real and synthetic

data.

I. INTRODUCTION

Burst suppression is an electroencephalographic (EEG)

pattern in which periods of high voltage activity (bursts)

alternate with periods of isoelectric quiescence (suppression)

(see Figure 1). It is characteristic of a profoundly inacti-

vated brain and occurs in conditions such as deep general

anesthesia [1], hypothermia [2] and coma [3]. That these

different conditions lead to seemingly similar brain activity

suggests that burst suppression is the result of a f undamental,

low-order process that is prominent when higher-level brain

activity is depressed.

The main features of burst suppression have been well de-

scribed [4], [5], [6]. Classically, burst suppression is thought

to be a global state where bursts begin and end nearly

simultaneously across the entire scalp. It is different from

typical faster EEG oscillatory patterns, in that suppression

epochs can be very irregular and may last several seconds.

Importantly, burst suppression is not a homogeneous state

but, instead, varies continuously as a function of brain inacti-

vation. As the brain becomes progressively more inactivated,

the amount of suppression, relative to the amount of burst,

increases. This variation has been traditionally quantiﬁed

with the burst suppression ratio [6], which measures the

amount of suppression in a sliding window of EEG data.

Recent research on the burst suppression probability [7]

*This work has been supported by NIH DP1-OD003646 (to ENB).

SC holds a Career Award at the Scientiﬁc Interface from the Burroughs-

Wellcome Fund

1

Department of Anesthesia, Critical Care and Pain Medicine, Mas-

sachusetts General Hospital & Harvard Medical School, Boston, MA

3

Department of Brain and Cognitive Science, Massachusetts Institute of

Technology, Cambridge, MA

4

Department of Electrical and Systems Engineering, Washington Univer-

sity in St. Louis, St. Louis, MO, USA

5

Harvard-Massachusetts Institute of Technology Division of Health Sci-

ences and Technology, Massachusetts Institute of Technology, Cambridge,

MA

6

Institute for Medical Engineering and Sciences, Massachusetts Institute

of Technology, Cambridge, MA

7

Department of Neurology, Massachusetts General Hospital & Harvard

Medical School, Boston, MA

Fig. 1. Example of burst suppression. (A) Continuous EEG activity, (B)

Burst suppression

(BSP) has provided a statistically rigorous, and window-free,

approach to estimating the burst suppression state.

Here, we introduce a method for estimating not simply

burst suppression, but the underlying brain metabolic state.

Our method is based on a recent nonlinear, biophysical

model [5], which attributes the parametric increase in sup-

pression duration with brain inactivation to decreases in brain

metabolism.

We begin by characterizing the relationship between brain

metabolic state and observable EEG features, namely the

lengths and variability of bursts and suppressions. We then

introduce and ﬁt a reduced state-space model of burst

suppression to recordings from neurological intensive care

unit (ICU) patients. From this model, we demonstrate the

inference of the underlying metabolic state.

The remainder of this paper is organized as follows.

Section II provides a brief background on the biophysical

mechanisms of burst suppression and the resulting models.

Section III introduces the reduced state-space model and

methods for metabolic state inference. Brief conclusions are

formulated in Section IV.

II. BACKGROUND

A. Neurophysiology of Burst Suppression

Although many features of burst suppression have been

described, the neurophysiological mechanisms that are re-

sponsible for creating it are less well understood. In the

context of general anesthesia, the early work by Steriade [8]

helped establish certain neural correlates of burst suppres-

sion, describing the participation of different cell types in

bursts and suppressions, though an underlying mechanism

was not suggested. Other studies [9] have suggested that

burst suppression involves enhanced excitability in cortical

networks, and have implicated ﬂuctuations in calcium as

related to the alternations between bursts and suppressions.

B. Existing Models of Burst Suppression

A unifying biophysical model for burst suppression – one

that accounts for its characteristics, and also its range of

etiologies – was recently proposed [5]. The key insight of

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Fig. 2. ATP-based mechanism for burst suppression. ATP is depleted

through the course of each burst, leading to suppression. During suppression

ATP gradually recovers until, eventually, activity begins again

the model is that each of the conditions associated with burst

suppression (general anesthesia, hypoxic/ischemic coma, hy-

pothermia) is associated with decreased cerebral metabolic

rate of oxygen (CMRO). The model links this decrease in

CMRO to deﬁciencies in ATP (adenosine triphosphate, the

energetic substrate for neuronal activity) production in corti-

cal networks (see Figure 2). The termination of each burst is

a reﬂection of ATP consumption due to the neuronal activity

underlying fast EEG oscillations, whereas suppressions are

governed by the slow dynamics of ATP regeneration.

This model provided an explanation for why three cardinal

features of burst suppression – the spatial synchrony of bursts

onsets across the scalp, the increase in suppression durations

with increasing brain inactivation, and the long timescales

of suppressions – can arise across its disparate etiologies.

The present paper is intended to provide a simpliﬁcation

of the model in [5], and simultaneously, to describe a

fourth cardinal feature that was not previously explored,

namely the variability of burst lengths at different burst

suppression levels. This, in turn, enables the estimation of

brain metabolism (CMRO) from EEG recordings.

III. PROBABILISTIC MODELING AND

ESTIMATION OF BURST SUPPRESSION

A. Simpliﬁed Burst Suppression Model

Based on [5], we present a reduced order state-space

model for burst suppression governed by the following:

˙a = k

r

(1 − a) − k

c

u (a) . (1)

Here, a(t) is the concentration of local ATP in a cortical

region, k

c

is the rate of ATP consumption during each burst,

k

r

is the rate of ATP regeneration during each suppression,

and u (a ) indicates whether burst activity can or cannot be

sustained. We select

u (a) =

1 ˙a > 0 and 0 ≤ a < α

0 otherwise,

(2)

meaning that burst activity can only be initiated when ATP

levels increase beyond the threshold α.

By ﬁxing the parameter k

c

= 1, (1) can be rewritten as

˙a = x (1 − a) − u (a) , (3)

where x, a value from 0 to 1, is the brain metabolic state.

A value of x = 0 corresponds to f ull CMRO (when ATP

regeneration equals consumption), while x = 1 is complete

metabolic depression.

Fig. 3. Example of model output for different values of metabolic state.

(A) x = 0.8, (B) x = 0.1. Simulated EEG signal shown for schematic

purposes only.

Figure 3 illustrates the output of the model for two dif-

ferent values of x. When x is moderate, the model produces

epochs of burst and suppression that are commensurate in

length. When x is reduced to a low value, the bursts are much

shorter (due to more rapid consumption) and the suppressions

are longer (due to slower regeneration).

The model (1) offers increased analytical tractability as

compared to the full nonlinear model in [5]. In particular,

we can derive explicit expressions for burst and suppression

lengths (L

S

and L

B

) at different metabolic state levels as:

L

S

(x) = − log ¯α/x

L

B

(x) = − log

1−x

1− ¯αx

/x,

(4)

where

¯α = 1 − α. (5)

The burst suppression state itself can then be quantiﬁed in

terms of the suppression lengths, relative to the total length

of a burst-suppression cycle, speciﬁcally:

BS

Level

(x) =

L

S

(x)

L

S

(x) + L

B

(x)

=

log ¯α

log ¯α + log

1−x

1− ¯αx

(6)

Note that in practice, (6) can be estimated using the burst

suppression probability (BSP) [7] algorithm. Through (4)

and ( 6), we can estimate x based on measurement of burst

suppression and calculation of burst and suppression lengths

from the EEG.

B. Automatic EEG Segmentation

In order to infer the metabolic state in our model, we

must ﬁrst establish a method to segment EEG recordings into

7109

Fig. 4. Examples of ICU burst suppression with automatic segmentation.

Segmented bursts (i.e., n

t

= 0) are shown in red, while suppressions

(i.e., n

t

= 1) are blue. (A,B) Patterns containing epileptiform spikes,

(C,D) Patterns with distinct bursts and suppressions, (E,F) Patterns with

less distinct bursts

bursts and suppressions. That is, if x

t

, t = 0, 1, 2, ... is the

sampled EEG signal, then we must obtain a corresponding

binary series n

t

where n

t

= 1 if x

t

is in a suppression and

0 if it is in a burst.

While several algorithms have been developed for this

purpose [10], [11], we choose to use adaptive variance

thresholding as follows:

¯y

t

= γx

t

+ (1 − γ)¯y

t−1

(7)

s

2

t

= γ(x

t

− ¯y

t

)

2

+ (1 − γ)s

2

t−1

(8)

n

t

=

1 s

2

t

< v

2

threshold

0 otherwise,

(9)

where γ is a tunable ﬁlter parameter and v

2

thresold

is an

amplitude threshold. We have applied this method to a variety

of EEG recordings of burst suppression from the neurological

ICU [12] and, as illustrated in Figure 4, it can reliably

segment the EEG into bursts and suppressions.

From the binary signal n

t

it is straightforward to obtain

empirical lengths of bursts and s uppression (simply, the

lengths of consecutive 0s or 1s), facilitating estimation of

metabolic state.

C. Inference of Metabolic State

In order to estimate the metabolic state x as a function

of time, and to account for anticipated stochastic effects in

burst and suppression lengths, we introduce a probabilistic

model as follows:

x

t

= min (max (x

t−1

+ v

t

, 0) , 1) , v

t

∼ N (0, σ) (10)

This model is a rectiﬁed Gaussian random walk and, if σ

is suitably small, implies that x does not exhibit large and

sudden temporal changes.

We will, furthermore, make a Markovian assumption that

p (x

t

|x

0

, x

1

, ..., x

t−1

) = p (x

t

|x

t−1

) (11)

and, in particular, that

p (n

t

|H (n, L, x)) = p (n

t

|n

t−1

, L

t−1

, x

t−1

) , (12)

where L

i

denotes the length of the i

th

event (either a burst

or suppression) and H(·) denotes the entire history.

What remains is to deﬁne the probabilities for continua-

tion:

p (n

t

= 1|n

t−1

= 1, L

t−1

, x

t−1

)

p (n

t

= 0|n

t−1

= 0, L

t−1

, x

t−1

)

(13)

and switching:

p (n

t

= 1|n

t−1

= 0, L

t−1

, x

t−1

)

p (n

t

= 0|n

t−1

= 1, L

t−1

, x

t−1

)

(14)

Based on the characterization from (4) and (6), we choose to

model these probabilities using the Weibull hazard function

h (t; λ, θ) =

θ

λ

t

λ

θ−1

, (15)

and its cumulative distribution function (CDF)

F (t; λ, θ) = 1 − exp

−

t

λ

θ

. (16)

Note that (15) and (16) are common in medical survival

analysis and reliability engineering.

We proceed to ﬁt (16) to the burst suppression level,

which can be well-estimated from the segmented EEG using

the burst suppression probability (BSP) algorithm [7]. In

particular, we compute an empirical CDF for (13) and ( 14)

by ﬁnding, for each suppression and burst, the correspond-

ing BSP level. We then ﬁt (16) to these CDFs using the

constraints

λ (BSP ) = a

1

exp (BSP × b

1

) , θ = c

1

(17)

for bursts and

λ (BSP ) = a

2

exp ((1 − BSP ) × b

2

) , θ = c

2

(18)

for suppressions. For this, we use a nonlinear least squares

numerical method over the free parameters a

i

, b

i

, c

i

. Figure

5 illustrates the empirical CDF for switching f rom the EEGs

of 20 ICU patients

1

and the resulting ﬁt for two BSP levels.

In both cases, the functions (17)-(18), together with (16),

are able to closely match the empirical CDFs. Figure 6

illustrates these ﬁts, as compared to the empirical CDFs for

switching, across the entire range of BSP values. As shown,

the resulting model characterization is close to what we ﬁnd

from our data.

The one-to-one relationship (6) relates our continuation

and switching functions (f or BSP) directly to metabolic state.

We can thus proceed t o perform inference of the metabolic

state through a direct application of Bayes formula to (12).

We illustrate the estimation using synthetic data generated

from the model (1). Figure 7A illustrates the burst and

suppression output (n

t

) from the model when x(t) is a

realization of the random walk (10). Through (12)-(16), and

1

These data were collected at the Massachusetts General Hospital as part

of routine clinical monitoring and with institutional review board approval.

7110

Fig. 5. Example of CDF for switching and resulting ﬁts for two BSP

levels. (A) BSP of 0.2, (B) BSP of 0.7

Fig. 6. Empirical

1

and ﬁt switching probability functions vs. BSP for

suppressions (A,B) and bursts (C,D). The ﬁtted functions (B,D) closely

match the empirical CDFs (A,C). White indicates values close to 1 (high

probability of switching) whereas black indicates values close to 0 (low

probability of switching).

the ﬁts of (17)-(18) obtained empirically from our ICU data

(i.e., Figure 6), we obtain the posterior probability density

function of metabolic state x at each point in time. The

mean of each distribution is the metabolic state estimate,

which is plotted in Figure 7C and compared with the true

value. Clearly, the estimate closely tracks the true value. One

feature of note is that the estimate does not immediately

change at each switch from burst to suppression. Instead, and

consistent with our model, it remains stable during each burst

and suppression until such time as its length is improbable

given the current BSP estimate.

IV. CONCLUSIONS

We have provided a reduced-order model for burst sup-

pression that links the EEG directly to reductions in cerebral

metabolic rate. From this model, we developed a probabilis-

tic inference s cheme to estimate brain metabolic state from

measured EEG activity. The resulting method was ﬁt and

tested on EEG data gathered from patients in the neurological

ICU. We then tested the method on synthetic burst suppres-

sion data, showing correct inference of metabolic state.

Further testing is, of course, necessary to validate the

use of this method in the clinical setting. Nevertheless, the

model provides justiﬁcation for t he practice of pharmaco-

logically inducing burst suppression as a therapeutic target

for brain protection in neurological intensive care settings

such as unrelenting seizures (refractory status epilepticus),

severe traumatic brain injury, and in cardiac surgery during

Fig. 7. Example of inference of metabolic state from simulated burst

suppression. (A) Simulated bursts and suppressions from (1), (B) Proba-

bility d ensity function of metabolic state x estimated from (12)-(18) (and

corresponding ﬁts). (C) Inferred x (red trace) as compared to the true value

used to generate (A) (blue trace).

circulatory arrest [13]. The model and estimation scheme

may also help inform strategies for optimizing burst sup-

pression when using anesthetic drugs. An eventual goal is to

provide a neurophysiologically-principled basis for inferring

and tracking brain metabolism in the ICU or surgical settings.

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- CitationsCitations5
- ReferencesReferences13

- "All EEG data were segmented into a binary sequence of burst and suppression epochs using a previously validated automated suppression detection algorithm [11]. The resulting binary signal was then filtered to produce a continuous measure of burst suppression depth, the BSP ('burst suppression probability'), which quantifies the instantaneous the probability of being in the suppressed state [12]. "

[Show abstract] [Hide abstract]**ABSTRACT:**Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop lifelong cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude " burst " periods interrupted by sustained low-amplitude " suppression " periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient's underlying brain function.- "8. Seizure detection algorithms and automated background assessment: Most automated seizure detection algorithms were developed for ictal patterns seen in patients with established epilepsy and have not been validated in ICU populations with acute symptomatic seizures (Sackellares et al., 2011). Automated analysis of background patterns (e.g., burst suppression periodic patterns) is an active research area but is not in routine clinical use (Cloostermans et al., 2011; Shibasaki et al., 2014; Westover et al., 2013). "

[Show abstract] [Hide abstract]**ABSTRACT:**Introduction: Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance. Methods: The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society developed expert consensus recommendations on the use of CCEEG in critically ill adults and children. Recommendations: The consensus panel describes the qualifications and responsibilities of CCEEG personnel including neurodiagnostic technologists and interpreting physicians. The panel outlines required equipment for CCEEG, including electrodes, EEG machine and amplifier specifications, equipment for polygraphic data acquisition, EEG and video review machines, central monitoring equipment, and network, remote access, and data storage equipment. The consensus panel also describes how CCEEG should be acquired, reviewed and interpreted. The panel suggests methods for patient selection and triage; initiation of CCEEG; daily maintenance of CCEEG; electrode removal and infection control; quantitative EEG techniques; EEG and behavioral monitoring by non-physician personnel; review, interpretation, and reports; and data storage protocols. Conclusion: Recommended qualifications for CCEEG personnel and CCEEG technical specifications will facilitate standardization of this emerging technology.- [Show abstract] [Hide abstract]
**ABSTRACT:**Objective: Deep hypothermia induces 'burst suppression' (BS), an electroencephalogram pattern with low-voltage 'suppressions' alternating with high-voltage 'bursts'. Current understanding of BS comes mainly from anesthesia studies, while hypothermia-induced BS has received little study. We set out to investigate the electroencephalogram changes induced by cooling the human brain through increasing depths of BS through isoelectricity. Methods: We recorded scalp electroencephalograms from eleven patients undergoing deep hypothermia during cardiac surgery with complete circulatory arrest, and analyzed these using methods of spectral analysis. Results: Within patients, the depth of BS systematically depends on the depth of hypothermia, though responses vary between patients except at temperature extremes. With decreasing temperature, burst lengths increase, and burst amplitudes and lengths decrease, while the spectral content of bursts remains constant. Conclusions: These findings support an existing theoretical model in which the common mechanism of burst suppression across diverse etiologies is the cyclical diffuse depletion of metabolic resources, and suggest the new hypothesis of local micro-network dropout to explain decreasing burst amplitudes at lower temperatures. Significance: These results pave the way for accurate noninvasive tracking of brain metabolic state during surgical procedures under deep hypothermia, and suggest new testable predictions about the network mechanisms underlying burst suppression.

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