How do you approach management of an ICU patient with brief potentially ictal rhythmic discharges (BIRDs) on EEG?

This is a very challenging question, and the clinical importance of BIRDs, besides being associated with an increased frequency of seizures (Yoo et al., PMID 24535702 ), is unclear. I am a neurointensivist, and in general, I do not escalate therapy for intermittent BIRDs unless we identify concomitant seizures on EEG. The presence of BIRDs will also lead me to monitor the patient with an EEG for a longer duration, often for several days or longer.

That being said, if the BIRDs are frequent (no ex...

BIRDs are ictal appearing rhythmic discharges that have been shown to correlate with increased seizure risk in critically ill (and non critically ill) patients, leading to worse clinical outcomes. They are focal or generalized rhythmic activity >4 Hz lasting ≥0.5 to <10 seconds, not consistent with a known normal pattern or benign variant, not part of burst-suppression or burst-attenuation, without a definite clinical correlate, and have at least one of the following features:

a. Evolution (“evol...

With my usual caveat of, there are exceptions to everything I say...

I see BIRDs as seizures that do not last the arbitrary 10 seconds, and since we're likely talking about scalp EEG, they likely last 10 seconds or more, should you be monitoring intracranially. That being said, I see BIRDs as very brief seizures and treat them as such. The aggressiveness of treatment depends on the patient and the number of BIRDs.