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Burst suppression

Burst suppression is an electroencephalographic (EEG) pattern characterized by quasiperiodic alternations between bursts of high-voltage, mixed-frequency neuronal activity and periods of relative electrical quiescence or isoelectric suppression, reflecting a state of profound brain inactivation.^[1] These bursts typically last from hundreds of milliseconds to several seconds and exhibit broad-spectrum oscillations, while suppression phases can extend up to 10–20 seconds with minimal activity below 10 µV, often showing spatial inhomogeneity across scalp electrodes.^[2] The pattern is quantified by the burst suppression ratio (BSR), which measures the proportion of time spent in suppression and increases with deepening levels of cerebral compromise.^[1] This EEG phenomenon was first observed nearly a century ago in the context of deep anesthesia and formally termed "burst suppression" by researchers such as Swank and Watson in the mid-20th century, building on early EEG monitoring techniques.^[3] It has since been recognized as a hallmark of severely reduced cerebral metabolic rate for oxygen (CMRO₂), serving as a protective mechanism to preserve basic cellular function during metabolic stress by limiting energy demands.^[1] Burst suppression is not exclusive to anesthesia; it emerges in diverse pathological states, including hypoxic-ischemic encephalopathy, hypothermia, severe drug intoxications (e.g., barbiturates or propofol overdose), and genetic disorders like Ohtahara syndrome, an early infantile epileptic encephalopathy first described in 1976.^[2]^[3] Clinically, burst suppression is a critical biomarker in intensive care, guiding therapeutic coma induction for neuroprotection in conditions such as refractory status epilepticus or post-cardiac arrest recovery, where it correlates with suppressed heart rate and mean arterial pressure.^[2] In anesthesia, it indicates adequate dosing of agents like propofol or sevoflurane, though different drugs produce distinct burst morphologies—such as slower, more synchronized activity with GABAergic anesthetics.^[4] Prognostically, persistent burst suppression in comatose patients often signals poor neurological outcomes, though its presence alone does not preclude recovery, and it may exhibit spatial inhomogeneities across EEG channels.^[3] Emerging research explores its underlying neurophysiology, revealing cortical hyperexcitability during bursts due to impaired inhibition and potential thalamic involvement in pattern generation.^[5]

Definition and Overview

Definition

Burst suppression is an electroencephalography (EEG) pattern characterized by alternating periods of high-voltage bursts, consisting of sudden, high-amplitude electrical activity, and periods of near-flatline suppression with minimal brain electrical activity.^[1] This pattern reflects a state of profound neuronal inactivation, where the brain alternates between brief episodes of synchronized activity and extended quiescence.^[6] The bursts in this pattern exhibit amplitudes ranging from 75-250 μV and broad-spectrum oscillations including low-frequency components (0-7 Hz) such as slow waves, spikes, or sharp transients.^[7] In contrast, suppression phases last at least 0.5-1 second (often several seconds to 10-20 seconds in deep suppression), with amplitudes below 10 μV approaching an isoelectric line indicative of near-complete electrical silence.^[8]^[9] These characteristics distinguish burst suppression from normal brain activity, which maintains continuous, lower-amplitude oscillations without such profound interruptions.^[1] Burst suppression arises in conditions of severe brain depression, such as deep general anesthesia induced by agents like propofol or isoflurane, therapeutic hypothermia (e.g., during cardiac surgery at temperatures around 18°C), and severe encephalopathies including hypoxic-ischemic injury.^[1] First observed in 1936 during animal studies of anesthetic effects on feline cerebral cortices, the pattern is now recognized for its clinical utility in monitoring coma depth, particularly in neurocritical care.^[10]^[11] Unlike continuous slowing, where EEG shows persistent polymorphic delta activity without flatline intervals, or seizure activity featuring rhythmic, evolving discharges, burst suppression is marked by its intermittent, quasi-periodic structure and the stark contrast between active and suppressed phases.^[2] This differentiation is crucial for accurate interpretation in diagnostic settings.^[12]

Physiological and Pathological Contexts

Burst suppression is a normal physiological EEG pattern observed in premature neonates, reflecting the immature development of the cerebral cortex. In extremely preterm infants (gestational age <28 weeks), spontaneous bursts of neuronal activity alternate with periods of quiescence, serving as a marker of early cortical maturation and predicting neurodevelopmental outcomes.^[13] This pattern arises due to the underdeveloped synaptic connectivity and network organization in the immature brain, transitioning toward more continuous activity as gestation progresses.^[14] Therapeutically, burst suppression is induced in clinical settings to achieve deep brain inactivation for neuroprotection. High doses of general anesthetics such as propofol and sevoflurane reliably produce this pattern by enhancing inhibitory neurotransmission, while deep hypothermia (typically below 24.4°C) elicits it through reduced cerebral metabolic rate, often during cardiac surgery or post-arrest care.^[15] These interventions aim to conserve neuronal energy and mitigate secondary injury in at-risk patients.^[1] In pathological contexts, burst suppression emerges in severe comas associated with hypoxic-ischemic encephalopathy (HIE), where it correlates with profound brain dysfunction and poor prognosis following oxygen deprivation.^[16] It also appears in traumatic brain injury (TBI), signaling reduced cerebral metabolic demand and potentially offering neuroprotective benefits when sedation-induced.^[17] Metabolic disorders leading to coma, such as those involving oxidative stress or encephalopathy, can similarly trigger this pattern due to disrupted brain homeostasis.^[1] Furthermore, it characterizes epileptic encephalopathies like Ohtahara syndrome, an early infantile condition with intractable seizures and burst-suppression EEG from birth.^[18] Burst suppression represents a "default" brain state that promotes energy conservation during extreme stress or inactivation, characterized by a marked loss of network complexity and stereotyped activity.^[19] This state can manifest as symmetric patterns in global insults, reflecting widespread cortical involvement, or asymmetric patterns in focal injuries, such as unilateral lesions from trauma, indicating localized disruption.^[20]

Historical Development

Early Observations

The first observation of the burst suppression pattern in electroencephalography (EEG) was reported in 1936 by Derbyshire and colleagues during experiments on cats under deep anesthesia induced by tribromoethanol and other agents. They described alternating periods of high-amplitude electrical activity, termed "bursts," followed by intervals of relative quiescence or electrical silence in the cerebral cortex, which they attributed to the profound effects of anesthesia on neural function.^[21] This finding laid the experimental foundation for recognizing the pattern as a marker of depressed cortical activity, initially explored through direct recordings from the exposed cortex.^[22] In the 1940s, further studies in animal models, particularly felines and canines, reinforced these observations by linking the pattern to administration of barbiturates such as pentothal or amobarbital and inhalational agents like ether at deep levels of anesthesia. These experiments demonstrated the pattern's reproducibility, highlighting its association with systemic suppression of brain activity during pharmacological narcosis. Early researchers viewed the burst suppression as a physiological response to overwhelming inhibition, bordering on reversible neural inactivation.^[23]^[24] The term "burst-suppression" was formally coined in 1949 by Swank and Watson in their work on canine EEG under barbiturate anesthesia.^[25]

Terminology and Key Milestones

The term "burst-suppression" was coined in 1949 by Swank and Watson to describe the alternating high-voltage bursts and periods of electrical quiescence observed in electroencephalographic (EEG) recordings from the surgically exposed cortex of dogs under the influence of barbiturates and ether. This nomenclature formalized the pattern initially noted in animal models, providing a conceptual framework for its recognition as a marker of profound cerebral inactivation. In the 1960s, following foundational animal observations such as those in felines from 1936, the burst suppression pattern transitioned to clinical applications in humans, particularly for monitoring depth of anesthesia and assessing coma states through EEG analysis. This shift was driven by translations from experimental settings to bedside use, exemplified by reports of burst suppression in barbiturate-induced coma cases and intoxications, where the pattern indicated severe suppression of neural activity.^[26] The 1980s and 1990s marked significant advancements in quantification and clinical standardization. In 1988, Rampil and colleagues introduced the burst suppression ratio (BSR), a metric calculating the percentage of EEG time spent in suppression within a defined epoch, enabling precise titration of anesthetic depth and neuroprotection strategies. Concurrently, burst suppression gained recognition in neonatal EEG norms as a grave abnormality, often linked to hypoxic-ischemic encephalopathy and predictive of adverse neurodevelopmental outcomes, as detailed in pediatric studies from the late 1980s.^[27] From the 2000s onward, burst suppression was incorporated into neurocritical care guidelines for managing refractory status epilepticus, with recommendations to induce and sustain the pattern using continuous infusions of agents like propofol or barbiturates to halt electrographic seizures and mitigate brain injury. Recent investigations, including those from 2023, have begun elucidating underlying mechanisms such as ephaptic coupling in the generation of these patterns.^[28]

Pathophysiological Mechanisms

Cellular Mechanisms

Burst suppression at the cellular level arises from dynamic changes in neuronal excitability and synaptic efficacy, primarily driven by metabolic and ionic shifts during intense activity periods. During the burst phase, high-frequency firing depletes extracellular calcium ions, which are essential for synaptic vesicle release and neurotransmitter transmission. This depletion impairs excitatory synaptic function, leading to a rapid transition to the suppression phase characterized by neuronal hyperpolarization and quiescence.^[29] The suppression phase is further reinforced by increased potassium conductance across neuronal membranes, which hyperpolarizes cells and reduces their ability to fire action potentials. Concurrently, heightened GABAergic inhibition plays a critical role in dampening excitability; GABA_A receptors, when activated, promote chloride influx, further hyperpolarizing neurons and prolonging the silent period until ionic gradients recover sufficiently for the next burst. These mechanisms ensure alternating cycles of activity and recovery at the single-neuron level.^[23]^[15] Anesthetics like sevoflurane contribute to these processes by modulating inhibitory interneuron function, primarily through enhancement of GABA_A receptor-mediated inhibition, which disrupts balanced cortical inhibition and promotes the burst-suppression pattern. At clinically relevant concentrations, sevoflurane reduces overall cortical inhibitory tone while amplifying phasic GABAergic responses, leading to synaptic depression that favors suppression.^[30] Recent calcium imaging studies from 2025 have provided direct visualization of these dynamics, revealing that bursts involve highly synchronized firing across approximately 65% of pyramidal neurons, followed by a period of cellular exhaustion marked by reduced calcium transients and anti-correlated activity in about 20% of neurons. Parvalbumin-expressing interneurons are pivotal in this process, modulating burst termination through feedback inhibition to prevent overexcitation. These findings underscore the intrinsic cortical origins of burst suppression, inducible by deep anesthesia.^[31]

Network and Systemic Factors

Burst suppression emerges from interactions within neural circuits, where ephaptic coupling plays a key role in propagating bursts across cortical layers independent of synaptic transmission. In a 2023 computational and experimental study using rabbit models under sevoflurane anesthesia, ephaptic interactions via extracellular electric fields recruited neighboring pyramidal neurons during low inhibitory states, generating burst activity that propagated layer-wise without relying on chemical synapses. This mechanism highlights how local field effects can synchronize neuronal firing in suppressed states, mirroring aspects of epileptic bursts but with reduced magnitude.^[32] Intrinsic cortical dynamics further support burst suppression as a product of local generator networks, persisting even after deafferentation from subcortical inputs. In dissociated cortical cultures, which lack afferent connections, spontaneous global bursts continue due to inherent network excitability, demonstrating that cortical circuits alone can sustain the alternating pattern without thalamic or brainstem drive. This intrinsic mode underscores the cortex's capacity for self-generated suppression-burst cycles under profound inhibition.^[33] Systemic conditions modulate these network dynamics by altering metabolic and input availability. Hypothermia reduces cerebral metabolic rate of oxygen (CMRO₂), promoting burst suppression as energy conservation stabilizes neuronal membranes via ATP-sensitive potassium channels, with patterns reversing upon rewarming. Similarly, ischemia restricts oxygen supply, diminishing thalamocortical inputs and triggering transitions to burst suppression through metabolic depletion and reduced subcortical excitation.^[1] Age-dependent variations influence burst suppression morphology, with neonatal patterns appearing more fragmented owing to immature connectivity. In preterm infants, bursts exhibit scale-free dynamics and asymmetry tied to gestational age, reflecting underdeveloped cortical-thalamic synchrony that disrupts uniform propagation. This immaturity leads to discontinuous or irregular suppression-burst alternations, distinct from the more coherent adult forms.^[13]

Electrophysiological Characteristics

EEG Patterns

Burst suppression on electroencephalography (EEG) manifests as a quasi-periodic alternation between high-amplitude bursts of mixed-frequency activity and periods of relative electrical silence known as suppressions. The bursts are characterized by broad-spectrum oscillations, predominantly in the delta (0.5-4 Hz) and theta (4-8 Hz) ranges, often interspersed with faster alpha (8-13 Hz) or beta (13-30 Hz) components, reflecting a resumption of cortical excitability. These bursts typically exhibit high amplitudes exceeding 50 μV, varying by the inducing agent or condition, and last 1-10 seconds, with durations shortening as the state deepens. Burst morphology varies by inducing agent; for example, propofol often features prominent alpha (8-13 Hz) rhythms during bursts, while other anesthetics may show more delta-dominant activity.^[34]^[6]^[2] Suppressions, in contrast, show near-isoelectric activity with amplitudes below 5-10 μV, indicating widespread neuronal quiescence, and their durations progressively lengthen—from seconds in lighter states to over 10 seconds or even minutes in deeper suppression, such as during profound anesthesia or hypothermia. This temporal evolution contributes to the pseudo-rhythmic nature of the pattern, where interburst intervals increase, leading to a higher proportion of suppression time. The pattern is often quantified using the burst suppression ratio (BSR), which captures the fraction of time in suppression, and arises from mechanisms including altered calcium dynamics in neuronal populations.^[34]^[6]^[15] In terms of spatial distribution, burst suppression is often symmetric across hemispheres when induced by systemic factors like general anesthesia, though with potential asynchrony; bursts involve a median of 76% of channels, with full simultaneity across all channels in ~18% of cases. However, in pathological contexts such as focal lesions or certain encephalopathies, the pattern can appear asymmetric, with bursts and suppressions varying between hemispheres or regions. This distinction aids in etiological inference, as greater symmetry often correlates with diffuse metabolic or pharmacological suppression.^[34]^[2]^[6] Differentiation from artifacts or similar patterns is crucial for accurate interpretation; true suppressions maintain consistently low amplitudes (<5 μV) across channels without the irregular, high-frequency transients typical of muscle or movement artifacts, which can be confirmed through multi-channel review and context (e.g., under sedation). Partial suppression, or burst-attenuation, features shorter or less profound low-voltage intervals (10-49% of the record) compared to the 50-99% suppression in full burst suppression, helping distinguish gradations of cortical depression.^[34]^[35]

Regional Variations

Burst suppression patterns during anesthesia often exhibit frontal predominance, reflecting the region's higher metabolic sensitivity to anesthetic agents. Frontal cortical areas show earlier and more pronounced suppression compared to posterior regions, as evidenced by synchronous burst onsets in frontal EEG recordings under propofol anesthesia, where alpha rhythms persist during bursts but broadband power drops sharply in suppressions. This regional bias arises from metabolic demands, with frontal zones experiencing greater ATP depletion and activation of potassium channels, leading to hypoexcitability at lower anesthetic doses than in parietal areas.^[1]^[36] In pathological conditions, burst suppression displays heterogeneity, such as asynchronous bursts in cases of multifocal injury or post-cardiac arrest encephalopathy. Following traumatic lesions like corpus callosum disruption, bursts become asymmetric and asynchronous across hemispheres, indicating disrupted inter-regional synchronization due to deafferentation. Similarly, in post-cardiac arrest patients under therapeutic hypothermia, regional spectral variations in bursts—such as theta-dominant activity in recovering cases—highlight heterogeneous network viability, with asynchronous patterns correlating to multifocal hypoxic damage. These deviations from standard burst-suppression EEG alternation underscore prognostic implications of asymmetry, often signaling poorer outcomes in diffuse injury.^[20]^[37] Neonatal burst suppression differs markedly, featuring more discontinuous and invariant bursts that reflect cerebral immaturity. In premature or full-term neonates with encephalopathy, EEG shows prolonged low-voltage intervals interspersed with stereotyped bursts, lacking the cyclic maturity seen in adults due to underdeveloped thalamocortical connections. This pattern, observed in conditions like hypoxic-ischemic injury, emphasizes regional autonomy in immature brains, where bursts remain invariant across recordings, aiding differentiation from seizures.^[38]^[39] Burst suppression can persist in isolated cortical regions following deafferentation, demonstrating intrinsic regional autonomy independent of subcortical inputs. In cases of functional disconnection, such as post-surgical undercut or traumatic isolation, stereo-EEG reveals ongoing suppression-burst activity confined to the deafferented cortex, with bursts maintaining local synchrony despite global asynchrony. This phenomenon, first noted in human cortical isolates, confirms that burst suppression emerges as a fundamental cortical response to profound inactivity, highlighting self-sustained dynamics in disconnected areas.^[40]^[41]

Quantification and Analysis

Traditional Metrics

The traditional metrics for quantifying burst suppression focus on time-domain measures that assess the proportion of EEG epochs dominated by suppression, providing a straightforward index of brain inactivation depth. These approaches rely on segmenting the EEG signal into burst and suppression phases based on amplitude criteria, without incorporating frequency or spectral analysis. The Burst Suppression Ratio (BSR) is the most established metric, representing the percentage of time spent in suppression during a fixed epoch, calculated as the total suppression duration divided by the epoch length. Epochs typically range from 1 to 60 seconds, with common durations of 15 or 60 seconds in clinical monitoring systems; a BSR of 0 indicates no suppression, while 1 (or 100%) signifies complete isoelectricity. This ratio correlates with reduced cerebral metabolism under deep anesthesia and was first formalized in investigations of inhalational agents' effects on porcine EEG patterns.^[42] Complementing the BSR, the Burst Suppression Probability (BSP) offers a dynamic, real-time alternative by estimating the instantaneous probability of suppression across short sliding windows, often on a sample-by-sample basis using probabilistic models fitted to the EEG signal. Unlike the epoch-based BSR, the BSP smooths fluctuations in suppression occurrence, enabling finer-grained tracking of transitions between burst and suppression states. It was developed to address the temporal resolution limitations of static ratios in critical care settings.^[43] These metrics depend on time-domain segmentation, where suppression is identified by thresholding EEG amplitude—typically below 10-20 μV for at least 0.5 seconds—while bursts are defined as higher-amplitude activity exceeding this threshold, often with rhythmic or polyspike components. Bandpass filtering (e.g., 0.5-30 Hz) precedes thresholding to enhance signal clarity.^[43] Despite their simplicity and widespread adoption, traditional metrics like BSR and BSP are sensitive to epoch length, as shorter windows may overlook prolonged suppressions and longer ones may average out variability, leading to inconsistent depth estimates. They are also vulnerable to artifacts, such as muscle activity or electrode noise, which can falsely elevate apparent burst activity or mask true suppression, potentially underestimating total suppression time by up to 40% compared to expert visual review.^[44]

Advanced Methods Including Machine Learning

Recent advancements in burst suppression analysis have incorporated machine learning techniques to enhance detection accuracy and adaptability, particularly in complex clinical scenarios. Unsupervised machine learning algorithms, such as spectral clustering applied to covariance matrices derived from short EEG windows, enable real-time segmentation of burst and suppression phases without requiring manual parameter tuning. This approach processes EEG data from neurocritical care patients, training on initial segments to classify patterns based on energy content and adapting to individual variability, achieving high sensitivity and specificity for burst detection. Similarly, unsupervised clustering using principal component analysis on quantitative burst suppression ratios has been employed to identify asymmetric patterns in refractory status epilepticus, revealing hemispheric differences that predict poor outcomes, with right-hemisphere features like skewness showing significant associations with non-survival.^[45] Probabilistic frameworks further refine detection by modeling burst suppression in the time-frequency domain, estimating the probabilities of burst, suppression, and artifact states through multinomial regression on frequency-binned EEG data. This method incorporates temporal constraints to ensure physiological plausibility, such as minimum burst durations, and demonstrates high agreement with expert visual scoring in anesthetic-induced EEG recordings. By leveraging iterative estimation techniques like reweighted least squares, these frameworks provide a robust basis for automated state classification across diverse suppression patterns. Integration of quantitative EEG features with machine learning has improved prognostic capabilities in comatose patients, particularly following cardiac arrest. Studies utilizing gradient boosting models on features including burst suppression ratios and functional connectivity achieve strong predictive performance for neurological recovery, with burst suppression thresholds in specific regions contributing substantially to outcome discrimination. Spectral edge frequency, as a key qEEG metric reflecting high-frequency EEG content, complements burst suppression probability in these models to forecast coma outcomes, enhancing early decision-making in intensive care settings.^[46] As of 2025, emerging deep learning approaches, such as convolutional neural networks, have shown promise in automated burst suppression detection with improved artifact handling and patient-specific adaptation.^[47] These advanced methods offer distinct advantages over traditional metrics like basic burst suppression ratios, including patient-specific adaptation through unsupervised learning, substantial reduction in manual oversight via automated real-time processing, and seamless integration into neurocritical monitoring systems for continuous assessment. Such innovations facilitate precise tracking of brain states in dynamic clinical environments, supporting timely interventions while minimizing inter-observer variability.^[45]

Clinical Applications

In Anesthesia and Sedation

Burst suppression is routinely induced and monitored in anesthesia and sedation to achieve deep levels of unconsciousness, particularly in intensive care unit (ICU) settings for managing refractory status epilepticus or elevated intracranial pressure (ICP). Clinicians typically target a burst suppression ratio (BSR) of 50-80% to balance effective cerebral metabolic suppression with avoidance of excessive neuronal inactivity, as this range correlates with reduced cerebral oxygen demand and ICP while minimizing risks of prolonged coma.^[48]^[49] Propofol is commonly used for rapid induction of burst suppression due to its fast onset and titratability, while sevoflurane serves for maintenance during prolonged sedation, allowing precise adjustment via inhalation to sustain the desired EEG pattern.^[50]^[51] Age-dependent dosing adjustments are critical for achieving burst suppression safely across patient populations. A 2025 study on young children undergoing anesthesia for congenital heart disease found that those under 12 months require lower relative doses of sevoflurane to reach equivalent BSR levels compared to children aged 12-36 months, owing to greater neurodevelopmental susceptibility to anesthetics.^[52] In adults, older patients exhibit increased propensity for burst suppression at lower doses, necessitating reduced propofol infusion rates to prevent over-suppression. Continuous EEG monitoring is essential to titrate agents, averting both intraoperative awareness from under-dosing and over-suppression, which can prolong recovery.^[53]^[54] Induced burst suppression has been linked to postoperative delirium (POD), with intraoperative patterns increasing risk by up to 41% in susceptible patients, particularly the elderly, due to potential neuroinflammatory effects from prolonged suppression.^[55] A 2025 meta-analysis confirmed this association, emphasizing the need for vigilant EEG-guided titration to mitigate POD incidence. In therapeutic hypothermia protocols following cardiac arrest, burst suppression is often observed or intentionally augmented to protect ischemic brain tissue, as hypothermia enhances suppression depth and may improve neurological recovery by reducing metabolic stress.^[56]

In Neurological Disorders

Burst suppression is employed as a therapeutic strategy in refractory status epilepticus (RSE), where induction aims to achieve a comatose state to interrupt ongoing seizures by reducing neuronal excitability.^[57] This approach typically involves anesthetic agents such as propofol or midazolam to target a burst suppression ratio (BSR) of 0.5 or greater, thereby suppressing epileptiform activity.^[57] In particular, for POLG-related RSE, a mitochondrial disorder prone to recurrent seizures, induced burst suppression has been investigated for its effects on seizure control and recurrence, with a 2025 study highlighting its application in this subgroup to assess long-term suppression efficacy.^[58] In neonatal epileptic encephalopathies, burst suppression serves as a key diagnostic marker on electroencephalography (EEG). Ohtahara syndrome, also known as early infantile epileptic encephalopathy with suppression-burst, is characterized by a persistent suppression-burst pattern across wakefulness and sleep, often appearing within the first weeks of life and aiding in early differentiation from other seizure disorders.^[18] Similarly, early myoclonic encephalopathy exhibits this EEG signature, featuring myoclonic jerks alongside bursts of high-amplitude activity alternating with voltage suppression, which supports its classification as a distinct suppression-burst encephalopathy.^[18] These patterns are essential for diagnosis, as they correlate with underlying structural or genetic etiologies and guide initial anticonvulsant trials. Monitoring burst suppression in traumatic brain injury (TBI) provides insights into neuroprotection by assessing cerebral metabolic demands during acute phases. Sedation-induced burst suppression has been linked to favorable recovery trajectories, as observed in a 2021 cohort where patients achieving this EEG state showed improved outcomes at discharge and six-month follow-up, suggesting a role in mitigating secondary brain injury through reduced excitotoxicity.^[59] Continuous EEG surveillance allows clinicians to titrate interventions that promote burst suppression, potentially preserving neuronal integrity in the context of elevated intracranial pressure. In vascular events such as ischemic strokes or perioperative cerebral hypoperfusion, interventions targeting cerebral desaturation can help mitigate the onset of burst suppression, which signals profound metabolic compromise. A 2025 analysis of concurrent cerebral desaturation and burst suppression in high-risk procedures demonstrated that prompt hemodynamic optimizations, including blood pressure augmentation, reduced the incidence of this EEG pattern, thereby supporting cerebral oxygenation and preventing ischemic progression.^[60]

Prognosis and Outcomes

In Adults and Critical Care

In adult patients following cardiac arrest, a high burst suppression ratio (BSR) exceeding 50% is strongly associated with poor neurological outcomes, reflecting severe brain injury and reduced likelihood of recovery. This pattern, often observed on electroencephalography (EEG) within the first 72 hours post-arrest, indicates profound suppression of cortical activity and correlates with irreversible neuronal damage. Studies have shown that such high BSR levels predict unfavorable prognoses with high specificity, guiding decisions on withdrawal of life support in intensive care units (ICUs).^[61] The 2025 American Heart Association guidelines recommend incorporating burst suppression patterns into multimodal prognostication models for post-cardiac arrest patients to predict unfavorable outcomes with high specificity when combined with other assessments.^[62] The presence of heterogeneous burst suppression persisting beyond 24 hours further enhances the predictive value for poor outcomes, as it signifies ongoing instability in brain network dynamics rather than a transient response to hypoxia. A 2025 multicenter cohort study demonstrated that incorporating this late EEG pattern into multimodal prognostication models significantly improves sensitivity for identifying non-survivors without increasing false positives, allowing for more accurate timing of outcome predictions up to 36 hours post-arrest. This heterogeneity, characterized by irregular burst morphology and amplitude, contrasts with more uniform patterns and underscores the evolving nature of postanoxic encephalopathy in critical care settings.^[61] In refractory status epilepticus (RSE), pharmacologically induced burst suppression is achieved in approximately 20% of cases without cerebral anoxia but does not improve seizure control or clinical outcomes, with an overall mortality rate of about 35%, influenced by underlying etiology and treatment duration.^[63] This dual role highlights the trade-off in critical care, where short-term seizure suppression may preserve brain function but extended suppression exacerbates systemic complications like hypotension and infection. A 2025 study frames burst suppression as a marker of diminished network complexity in comatose adults, directly correlating with coma depth and failure to recover consciousness. Functional connectivity analyses in post-cardiac arrest patients showed that burst suppression disrupts default mode network integrity, leading to persistent unresponsiveness and poor long-term outcomes in up to 80% of cases. This loss of complexity, quantified via EEG spectral measures, reflects a breakdown in thalamocortical interactions essential for arousal, providing a mechanistic link to prognostic stratification in ICUs.^[19] Key factors influencing prognosis in these scenarios include the duration of suppression and the symmetry of burst patterns. Prolonged suppression beyond 48 hours independently predicts higher mortality and neurological deficits, as it amplifies metabolic stress on vulnerable brain regions. Symmetric bursts, often identical across hemispheres, indicate diffuse injury and worsen outcomes compared to asymmetric patterns, which may suggest focal recovery potential; quantitative EEG metrics like burst similarity indices above 0.5 confirm this association with non-recovery.^[64]^[65]

In Neonates

In premature neonates, transient periods of EEG discontinuity resembling burst suppression can occur as part of normal developmental maturation, particularly in those born before 30 weeks gestation, where interburst intervals gradually shorten with age.^[66] However, true persistent burst suppression, characterized by prolonged flat suppressions and abnormal bursts lacking normal EEG features, is pathological even in preterm infants and indicates severe underlying brain dysfunction.^[67] In term neonates with hypoxic-ischemic encephalopathy (HIE), persistent burst suppression on EEG is a grave indicator, associated with death or severe neurodevelopmental disability in approximately 80-90% of cases, based on pre-therapeutic hypothermia era studies where 13 of 15 infants with this pattern had poor outcomes, including high mortality and profound motor/cognitive impairments.^[68]^[69] Therapeutic hypothermia for perinatal asphyxia has improved prognoses, with early burst suppression metrics during treatment predicting outcomes; notably, about 40% of affected neonates achieve good neurodevelopmental recovery despite the initial pattern, as evidenced by longitudinal EEG monitoring in cohorts from 2014-2021.^[70] Burst suppression is also a hallmark of neonatal epileptic encephalopathies, such as Ohtahara syndrome, where invariant, high-amplitude bursts alternate with profound suppressions, often linked to early myoclonic encephalopathy and carrying a poor prognosis with intractable seizures and developmental arrest.^[71] Recent 2025 studies on age-dependent anesthesia in neonates and young children with congenital heart disease reveal fragmented burst suppression patterns, with infants under 12 months showing heightened susceptibility to suppression at deeper anesthetic levels compared to older toddlers, as measured by spectral edge frequency correlations during procedures.^[52]

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American Clinical Neurophysiology Society's Standardized Critical ...
For patients with refractory status epilepticus treated with anesthetic-induced coma, the presence of “highly epileptiform” bursts suggested that an attempted ...
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[PDF] ACNS GUIDELINE
Jan 27, 2021 · For example, a record with 2 second bursts alternating with 8 seconds of suppression, as shown here, would be. Burst-Suppression with a ...Missing: global | Show results with:global
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Hypersensitivity of the Anesthesia-Induced Comatose Brain
Sep 26, 2007 · Burst suppression (BS) activity was first described by Swank and Watson (1949). Its main feature at the EEG level consists of quasi-periodical ...
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Spectral content of electroencephalographic burst suppression ...
To assess the potential biological significance of variations in burst-suppression patterns (BSP) after cardiac arrest in relation to recovery of consciousness.
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Background suppression of electrical activity is a potential biomarker ...
The discontinuous or “immature” pattern was marked by periods of low EEG activity in alpha, beta, and gamma frequency bands, and these periods of inactivity ...
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EEG Abnormalities of Premature and Full-Term Neonates | Obgyn Key
Mar 8, 2018 · This term refers to an EEG in which the developmental characteristics in all states are immature for the reported gestational or CA. If the ...
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Suppression-burst activity from isolated cerebral cortex in man
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ASYNCHRONIC AND ASYMMETRIC BURST-SUPPRESSION IN A ...
BS is normally synchronous and symmetric. Since BS can be seen in isolated cortex, the mechanism is thought to be cortical deafferentation. Case Report: 19 year ...
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https://pmc.ncbi.nlm.nih.gov/articles/PMC9273272/
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https://obgynkey.com/eeg-abnormalities-of-premature-and-full-term-neonates/
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Association Between Induced Burst Suppression and Clinical ... - NIH
May 9, 2023 · The proportion of suppression/attenuation must be between 50% and 99% of the recording, which is based on an experts' consensus. As part of ...
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What is burst suppression? - Dr.Oracle
Jun 30, 2025 · ... goal of achieving a suppression ratio of 50-90% and reducing cerebral oxygen consumption and intracranial pressure. Continuous EEG ...
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Does Electroencephalographic Burst Suppression still play a role in ...
The electroencephalographic pattern of burst suppression (BS) is commonly found during the general anesthetic state as a result of increased anesthetic depth.
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The Ageing Brain: Age-dependent changes in the ... - PubMed Central
Jul 14, 2015 · The probability that patients showed an episode of burst suppression increased with age for both propofol and sevoflurane (Fig. 5a and b) ...
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Age-Dependent Burst Suppression During Anesthesia in Young ...
Oct 17, 2025 · The objectives of this study were to assess the depth of anesthesia by measuring bilateral spectral edge frequency (SEF) and to determine the ...
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Age-Dependent Changes in the Propofol-Induced ... - Frontiers
Elderly adults receiving propofol for maintenance of general anesthesia show significantly reduced frontal alpha oscillation power and increased probability of ...<|separator|>
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Neuromonitoring and Anesthesia: Why is it important to understand ...
Aug 19, 2024 · Burst Suppression During General Anesthesia and Postoperative ... The information provided by noninvasive frontal EEG monitors is helpful for ...
[50]
Intraoperative electroencephalogram patterns as predictors of ...
May 12, 2024 · Conclusions: This study revealed a 41% increase in the relative risk of developing POD in cases where a burst suppression pattern was present.
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A Systematic Review and Meta-analysis - PubMed
Jan 1, 2025 · The meta-analysis suggests an association between intraoperative burst suppression and postoperative delirium; however, the quality of evidence was very low.
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Post-cardiac arrest temperature manipulation alters early EEG ...
Hypothermia improves outcomes after cardiac arrest (CA), while hyperthermia worsens injury. EEG recovers through periodic bursting from isoelectricity after ...
[53]
Association Between Induced Burst Suppression and Clinical ...
Burst suppression describes an EEG pattern consisting of alternating epochs of high-voltage broad-spectrum oscillations (bursts) and electrical suppression.
[54]
The impact of induced burst suppression on outcomes in patients ...
May 23, 2025 · We aimed to study the impact of induced burst suppression on seizure control and survival in patients with POLG-related refractory status epilepticus.Missing: cases | Show results with:cases
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Sedation-Induced Burst Suppression Predicts Positive Outcome ...
Dec 22, 2021 · We examined the relationship between sedation-induced burst-suppression (SIBS) and outcome at hospital discharge and at 6-month follow up in ...
[56]
Incidence of Concurrent Cerebral Desaturation and ... - PubMed
May 1, 2025 · Targeted interventions to address cerebral desaturation may assist in mitigating burst suppression and consequently enhance postoperative ...
[57]
A 9-Year Cohort Study - PubMed
Feb 27, 2024 · Association Between Induced Burst-Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study.Missing: seizure control mortality
[58]
Separate functional and structural cerebral mechanisms relate to ...
We hypothesize that functional and structural changes follow separate pathways towards persistent coma or recovery after a cardiac arrest. ... burst suppression) ...
[59]
Burst Suppression: Causes and Effects on Mortality in Critical Illness
Prior studies in mechanically ventilated ICU patients found that burst suppression is associated with increased 30-day, 6-month, and one-year mortality, and ...
[60]
[PDF] MIT Open Access Articles Early Burst Suppression Similarity ...
All subjects in our cohort with average burst similarity above 0.5 using XCORR had poor outcome, corroborating several studies that have identified burst ...
[61]
[PDF] Neonates Termiology - American Clinical Neurophysiology Society
Burst Suppression. Further disruption of EEG continuity results in the more severe burst suppression pattern. This consists of invariant, abnormally composed ...Missing: norms | Show results with:norms
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Abnormal Neonatal EEG - StatPearls - NCBI Bookshelf - NIH
Severe background EEG abnormalities such as burst suppression have been associated with early myoclonic encephalopathy (EME) and Ohtahara syndrome (Early ...
[63]
EEG and long-term outcome of term infants with neonatal hypoxic ...
A burst suppression pattern (BSP) on the EEG in term infants who have evidence of neonatal HIE has been shown to be predictive of a grave prognosis (Holmes et ...
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https://pmc.ncbi.nlm.nih.gov/articles/PMC7483190/
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Neuromonitoring in Neonatal-Onset Epileptic Encephalopathies
Feb 1, 2021 · In neonates with HIE undergoing therapeutic hypothermia, burst suppression pattern is associated with good outcomes in about 40% of the patients ...Abstract · Introduction · Neonatal EEG · EEG Monitoring in Neonatal...<|separator|>
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Ohtahara Syndrome and Early Myoclonic Encephalopathy
Electroencephalogram indicates typical suppression burst pattern that can be observed in both Ohtahara syndrome and early myoclonic encephalopathy. This ...